Provider Demographics
NPI:1538715248
Name:MCQUITTY, OCTAVIA LOUISE (OCTAVIA)
Entity type:Individual
Prefix:MRS
First Name:OCTAVIA
Middle Name:LOUISE
Last Name:MCQUITTY
Suffix:
Gender:F
Credentials:OCTAVIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 ROCHEPORT ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MO
Mailing Address - Zip Code:65248-1290
Mailing Address - Country:US
Mailing Address - Phone:660-888-0669
Mailing Address - Fax:
Practice Address - Street 1:504 ROCHEPORT ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1290
Practice Address - Country:US
Practice Address - Phone:660-888-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion