Provider Demographics
NPI:1124471818
Name:QUALLS, KATHY
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:QUALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-1725
Mailing Address - Country:US
Mailing Address - Phone:931-836-2201
Mailing Address - Fax:931-836-3580
Practice Address - Street 1:135 WALKER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-1725
Practice Address - Country:US
Practice Address - Phone:931-836-2201
Practice Address - Fax:931-836-3580
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN87021164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse