Provider Demographics
NPI:1215554647
Name:CHASTANT-QUALLS, MEAGAN DUVAL (FNP)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:DUVAL
Last Name:CHASTANT-QUALLS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7651 TCHULAHOMA RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9227
Mailing Address - Country:US
Mailing Address - Phone:662-349-0980
Mailing Address - Fax:662-349-0990
Practice Address - Street 1:7651 TCHULAHOMA RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9227
Practice Address - Country:US
Practice Address - Phone:662-349-0980
Practice Address - Fax:662-349-0990
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCHAS-Q9QY9E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine