Provider Demographics
NPI:1073384103
Name:BLODGETT-GALLAHAN, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
Last Name:BLODGETT-GALLAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 W VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-7232
Mailing Address - Country:US
Mailing Address - Phone:607-342-6203
Mailing Address - Fax:
Practice Address - Street 1:43 W VISTA CIR
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-7232
Practice Address - Country:US
Practice Address - Phone:607-342-6203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236422367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife