1639136609 NPI number — KRISTI QUALLS PRICE M.D.

Table of content: KRISTI QUALLS PRICE M.D. (NPI 1639136609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639136609 NPI number — KRISTI QUALLS PRICE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRICE
Provider First Name:
KRISTI
Provider Middle Name:
QUALLS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STATLER
Provider Other First Name:
KRISTI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639136609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72437-0505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-237-1055
Provider Business Mailing Address Fax Number:
870-237-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
803 HIGHWAY 18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72437-9603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-561-3300
Provider Business Practice Location Address Fax Number:
870-561-3307
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  E-3986 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 154227001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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