Provider Demographics
NPI:1083670889
Name:QUALLS, JANA M (FNP)
Entity type:Individual
Prefix:MS
First Name:JANA
Middle Name:M
Last Name:QUALLS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3117 W AUGUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-5362
Mailing Address - Country:US
Mailing Address - Phone:208-957-7808
Mailing Address - Fax:949-695-2456
Practice Address - Street 1:913 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9764
Practice Address - Country:US
Practice Address - Phone:208-957-7808
Practice Address - Fax:949-957-2456
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7267363LC0200X
IDNP-1631A363LF0000X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P43486Medicare UPIN
3909774Medicare ID - Type UnspecifiedTN MEDICARE
TNP43486Medicare UPIN