Provider Demographics
NPI:1487636932
Name:GALL, ELIZABETH FUNKE (RN, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:FUNKE
Last Name:GALL
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:FUNKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, FNP-C
Mailing Address - Street 1:2315 STOCKTON BLVD
Mailing Address - Street 2:ROOM 1P517 CARDIOLOGY
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2201
Mailing Address - Country:US
Mailing Address - Phone:916-703-6421
Mailing Address - Fax:
Practice Address - Street 1:2360 STOCKTON BLVD
Practice Address - Street 2:HEMOPHILIA TREATMENT CENTER
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2209
Practice Address - Country:US
Practice Address - Phone:916-734-7624
Practice Address - Fax:916-734-3951
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413322363LF0000X
CA11294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP71898Medicare UPIN
CA222136392Medicare ID - Type Unspecified