Provider Demographics
NPI:1487162483
Name:STATEN, KUALANI DEJALE' (CNA)
Entity type:Individual
Prefix:
First Name:KUALANI
Middle Name:DEJALE'
Last Name:STATEN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:KUALANI
Other - Middle Name:
Other - Last Name:STATEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNA
Mailing Address - Street 1:4973 URSULA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239-4345
Mailing Address - Country:US
Mailing Address - Phone:720-767-6202
Mailing Address - Fax:
Practice Address - Street 1:4973 URSULA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239-4345
Practice Address - Country:US
Practice Address - Phone:720-767-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO374U00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty