Provider Demographics
NPI:1508849290
Name:GALLAHER, STEPHANIE ANN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:GALLAHER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2498
Mailing Address - Fax:208-262-7461
Practice Address - Street 1:315 W DALTON AVE STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8600
Practice Address - Country:US
Practice Address - Phone:208-209-2066
Practice Address - Fax:208-209-2076
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID73290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1508849290Medicaid