Provider Demographics
NPI:1124251178
Name:QUALLS, MARY KIM (MSORT/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KIM
Last Name:QUALLS
Suffix:
Gender:M
Credentials:MSORT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 DONALDSON RD
Mailing Address - Street 2:
Mailing Address - City:NEBO
Mailing Address - State:KY
Mailing Address - Zip Code:42441-9339
Mailing Address - Country:US
Mailing Address - Phone:270-249-3910
Mailing Address - Fax:
Practice Address - Street 1:300 DONALDSON RD
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:KY
Practice Address - Zip Code:42441-9339
Practice Address - Country:US
Practice Address - Phone:270-249-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3361174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist