Provider Demographics
NPI:1235689498
Name:GALLEGOS, MERRISSA DANYOL (NP)
Entity Type:Individual
Prefix:
First Name:MERRISSA
Middle Name:DANYOL
Last Name:GALLEGOS
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 1:2850 HOG MOUNTAIN RD
Mailing Address - Street 2:#102
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2850 HOG MOUNTAIN RD
Practice Address - Street 2:#102
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5934
Practice Address - Country:US
Practice Address - Phone:770-614-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA244062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily