Provider Demographics
NPI:1497752752
Name:GALLAGHER, SUSAN K (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:K
Other - Last Name:SHIVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:545 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-762-5560
Mailing Address - Fax:309-762-7351
Practice Address - Street 1:545 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-762-5560
Practice Address - Fax:309-762-7351
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004834367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1967679Medicaid
ILL99525Medicare PIN
ILR29775Medicare UPIN
IA1967679Medicaid