Provider Demographics
NPI:1275708745
Name:GALLIVAN, CAROL T (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:T
Last Name:GALLIVAN
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 1:1560 BEAM AVE STE E
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1171
Mailing Address - Country:US
Mailing Address - Phone:651-578-7000
Mailing Address - Fax:651-773-9646
Practice Address - Street 1:1560 BEAM AVE STE E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1171
Practice Address - Country:US
Practice Address - Phone:651-578-7000
Practice Address - Fax:651-773-9646
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0710769163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN960961012135OtherPREFERRED ONE