Provider Demographics
NPI:1376141317
Name:GALLO, OVSANNA (NP)
Entity Type:Individual
Prefix:
First Name:OVSANNA
Middle Name:
Last Name:GALLO
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 1:242 SEABERT RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3317
Mailing Address - Country:US
Mailing Address - Phone:843-424-9109
Mailing Address - Fax:
Practice Address - Street 1:4000 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7833
Practice Address - Country:US
Practice Address - Phone:843-390-8304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24328208M00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist