Provider Demographics
NPI:1609593334
Name:GALLEGOS, ALYCIA (FNP)
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ALYCIA
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 CASSANDRA LN
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-7067
Mailing Address - Country:US
Mailing Address - Phone:505-264-4309
Mailing Address - Fax:
Practice Address - Street 1:120 S 9TH ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3102
Practice Address - Country:US
Practice Address - Phone:505-861-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM70258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine