Provider Demographics
NPI:1235657289
Name:GALLANT, KRISTINA (NP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:GALLANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 TOY TOWN LN
Mailing Address - Street 2:
Mailing Address - City:WINCHENDON
Mailing Address - State:MA
Mailing Address - Zip Code:01475-2801
Mailing Address - Country:US
Mailing Address - Phone:978-821-7514
Mailing Address - Fax:
Practice Address - Street 1:114 MERRIAM AVE
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3175
Practice Address - Country:US
Practice Address - Phone:978-534-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN281732163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1235657289Medicaid