Provider Demographics
NPI:1164095600
Name:QUALLS, AMY (RNFA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:QUALLS
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 992
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76098-0992
Mailing Address - Country:US
Mailing Address - Phone:817-879-3269
Mailing Address - Fax:
Practice Address - Street 1:213 MARAL LN
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-1164
Practice Address - Country:US
Practice Address - Phone:817-879-3269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX849975163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant