Provider Demographics
NPI:1083883979
Name:GALLEGOS, JUANITA (RN)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 BRONX PARK E APT 4J
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-1236
Mailing Address - Country:US
Mailing Address - Phone:718-824-1638
Mailing Address - Fax:
Practice Address - Street 1:2160 BRONX PARK E APT 4J
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-1236
Practice Address - Country:US
Practice Address - Phone:718-824-1638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000486-1176B00000X
NY352675163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01779886Medicaid