Provider Demographics
NPI:1174130124
Name:QUEZADA, TONI RUTH
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:RUTH
Last Name:QUEZADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:RUTH
Other - Last Name:MEADVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:11567 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75708-3205
Mailing Address - Country:US
Mailing Address - Phone:903-805-1040
Mailing Address - Fax:
Practice Address - Street 1:11567 19TH AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-3205
Practice Address - Country:US
Practice Address - Phone:903-805-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX177135164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse