Provider Demographics
NPI:1932409091
Name:QUALLS, LISA M (DC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:QUALLS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 N SHORE RD
Mailing Address - Street 2:APT A
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-3425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 W 21ST ST
Practice Address - Street 2:SUITE E
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2200
Practice Address - Country:US
Practice Address - Phone:321-299-5310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556823111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor