Provider Demographics
NPI:1003853300
Name:GALLAGHER, JILL C (CRNA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 EAST OVERBROOK ST.
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206
Mailing Address - Country:US
Mailing Address - Phone:316-644-1193
Mailing Address - Fax:
Practice Address - Street 1:8330 E OVERBROOK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2326
Practice Address - Country:US
Practice Address - Phone:316-644-1193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS144635Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER