Provider Demographics
NPI:1043901143
Name:GALLEGOS, MARISSA ALEXANDRA (THW DOULA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ALEXANDRA
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:THW DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0075
Mailing Address - Country:US
Mailing Address - Phone:541-908-6919
Mailing Address - Fax:
Practice Address - Street 1:520 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6411
Practice Address - Country:US
Practice Address - Phone:541-908-6919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108581374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula