Provider Demographics
NPI:1750770053
Name:QUALLS, KRISTENE
Entity type:Individual
Prefix:
First Name:KRISTENE
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 1:29580 COUNTY ROAD 6
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-9513
Mailing Address - Country:US
Mailing Address - Phone:574-596-3258
Mailing Address - Fax:
Practice Address - Street 1:524 E MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6285
Practice Address - Country:US
Practice Address - Phone:574-256-2556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-10
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005344A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201282570Medicaid
IN201282570Medicaid