Provider Demographics
NPI:1194120964
Name:QUALLS, KATHLENE KRYN
Entity type:Individual
Prefix:MRS
First Name:KATHLENE
Middle Name:KRYN
Last Name:QUALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:KATHLENE
Other - Middle Name:KRYN
Other - Last Name:QUALLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DSC
Mailing Address - Street 1:401 N. BOGARD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7108
Mailing Address - Country:US
Mailing Address - Phone:907-357-2578
Mailing Address - Fax:
Practice Address - Street 1:401 N. BOGARD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7108
Practice Address - Country:US
Practice Address - Phone:907-357-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK8612251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics