Provider Demographics
NPI:1790521573
Name:QUINN, SHAVONDA (IBCLC, CLC)
Entity type:Individual
Prefix:
First Name:SHAVONDA
Middle Name:
Last Name:QUINN
Suffix:
Gender:F
Credentials:IBCLC, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PINE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBLUFF
Mailing Address - State:MS
Mailing Address - Zip Code:39741-9618
Mailing Address - Country:US
Mailing Address - Phone:662-251-7885
Mailing Address - Fax:
Practice Address - Street 1:200 PINE GROVE RD
Practice Address - Street 2:
Practice Address - City:CEDARBLUFF
Practice Address - State:MS
Practice Address - Zip Code:39741-9618
Practice Address - Country:US
Practice Address - Phone:662-251-7885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-307968174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN