Provider Demographics
NPI:1962860270
Name:QUALLS, YVETTE J
Entity Type:Individual
Prefix:MS
First Name:YVETTE
Middle Name:J
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 1:349 N PEARL ST APT 402
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1148
Mailing Address - Country:US
Mailing Address - Phone:508-510-4285
Mailing Address - Fax:508-510-4285
Practice Address - Street 1:349 N PEARL ST APT 402
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1148
Practice Address - Country:US
Practice Address - Phone:508-510-4285
Practice Address - Fax:508-510-4285
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251E00000X
MA2NNE20347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No347C00000XTransportation ServicesPrivate Vehicle