Provider Demographics
NPI:1689819682
Name:QUALLS, ELLEN LAVERA (APN)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:LAVERA
Last Name:QUALLS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72521-5010
Mailing Address - Country:US
Mailing Address - Phone:870-834-0581
Mailing Address - Fax:
Practice Address - Street 1:301 S MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:AR
Practice Address - Zip Code:72521-5010
Practice Address - Country:US
Practice Address - Phone:870-834-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-05
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03179364SA2100X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA03179OtherAPN LICENSE A03179
AR180502758Medicaid
AR5R233OtherBCBS
ARA03179OtherAPN LICENSE A03179