Provider Demographics
NPI:1023535218
Name:GALLAGHER, MARY LUCARELLI (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LUCARELLI
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CHRISTINE
Other - Last Name:LUCARELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7650 SW BEVELAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-601-3615
Mailing Address - Fax:503-646-1683
Practice Address - Street 1:7431 NE EVERGREEN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5831
Practice Address - Country:US
Practice Address - Phone:503-840-3400
Practice Address - Fax:503-840-3409
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR367A00000X
OR201607487RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500755020Medicaid