Provider Demographics
NPI:1407632995
Name:GALLUS, MADELEINE REGINA (LM CPM)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:REGINA
Last Name:GALLUS
Suffix:
Gender:F
Credentials:LM CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 N TUBSGATE PL APT 37
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5764
Mailing Address - Country:US
Mailing Address - Phone:208-518-9327
Mailing Address - Fax:
Practice Address - Street 1:5077 YORK AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7818
Practice Address - Country:US
Practice Address - Phone:208-518-9327
Practice Address - Fax:208-625-2067
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-146176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife