Basic Information
| Provider Information | |||||||||
| NPI: | 1265076053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUINETTE | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6901 SIMMONS LOOP FL 4 | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335789498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133028522 | ||||||||
| FaxNumber: | 8136056167 | ||||||||
| Practice Location | |||||||||
| Address1: | 6901 SIMMONS LOOP FL 4 | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335789498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133028522 | ||||||||
| FaxNumber: | 8136056167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2019 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN11005460 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 106159500 | 05 | FL | MEDICAID |