Provider Demographics
NPI:1336120096
Name:GALLOWAY, BONNIE LYNN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LYNN
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HOSPITAL DR
Mailing Address - Street 2:SUITE 312
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9362
Mailing Address - Country:US
Mailing Address - Phone:570-523-8700
Mailing Address - Fax:570-523-8705
Practice Address - Street 1:3 HOSPITAL DR
Practice Address - Street 2:SUITE 312
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9362
Practice Address - Country:US
Practice Address - Phone:570-523-8700
Practice Address - Fax:570-523-8705
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN72000123A367A00000X
PAMW010239176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200857240Medicaid
MI4088840-10Medicaid
IN000000577790OtherBCBS
MIN2097000-1Medicare ID - Type Unspecified
MI4088840-10Medicaid