Provider Demographics
NPI:1558360230
Name:PANGALLO, GEORGIANNE (NP)
Entity Type:Individual
Prefix:
First Name:GEORGIANNE
Middle Name:
Last Name:PANGALLO
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 1:198 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-2323
Mailing Address - Country:US
Mailing Address - Phone:317-739-0900
Mailing Address - Fax:708-394-0911
Practice Address - Street 1:198 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2323
Practice Address - Country:US
Practice Address - Phone:317-739-0900
Practice Address - Fax:708-394-0911
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002428363L00000X
IN71003618A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ58993Medicare UPIN
ILK23430Medicare PIN
ILP00401141Medicare PIN
ILK23431Medicare PIN