Provider Demographics
NPI:1902276967
Name:QUALLIOTINE, KERRY ANNA (RN)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ANNA
Last Name:QUALLIOTINE
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 1:580 BROADWAY RM 608
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-3258
Mailing Address - Country:US
Mailing Address - Phone:631-275-6967
Mailing Address - Fax:
Practice Address - Street 1:580 BROADWAY RM 608
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3258
Practice Address - Country:US
Practice Address - Phone:631-275-6967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY658594163W00000X
CA95033206163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse