Provider Demographics
NPI:1144967118
Name:GALLO MORENO, FERNANDA
Entity type:Individual
Prefix:
First Name:FERNANDA
Middle Name:
Last Name:GALLO MORENO
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 1:20 PEQUEA MANOR DR APT 2
Mailing Address - Street 2:
Mailing Address - City:GORDONVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17529-9520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 GREENTREE RD
Practice Address - Street 2:
Practice Address - City:QUARRYVILLE
Practice Address - State:PA
Practice Address - Zip Code:17566-9458
Practice Address - Country:US
Practice Address - Phone:717-806-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDJ000052175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath