Provider Demographics
NPI:1568909034
Name:QUALLO, TRISHANA SAMANTHA (RN)
Entity Type:Individual
Prefix:
First Name:TRISHANA
Middle Name:SAMANTHA
Last Name:QUALLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1743 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-1664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6801 LAKE WORTH RD
Practice Address - Street 2:307
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2955
Practice Address - Country:US
Practice Address - Phone:561-487-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9450285163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse