Provider Demographics
NPI:1245380518
Name:GALAN-DEJESUS, MIRIAM (NP)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:GALAN-DEJESUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:GALAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3241 WESTERN BRANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5260
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:400 W BRAMBLETON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1115
Practice Address - Country:US
Practice Address - Phone:757-623-8642
Practice Address - Fax:757-623-4640
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024116561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS66705Medicare UPIN