Provider Demographics
NPI:1619238367
Name:GALLEGOS, MARY WORRALL (RN, BSN, CHPN, PHN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:WORRALL
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:RN, BSN, CHPN, PHN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:WORRALL
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PHN
Mailing Address - Street 1:PO BOX 539
Mailing Address - Street 2:C/O SANTA YNEZ TRIBAL HEALTH CLINIC
Mailing Address - City:SANTA YNEZ
Mailing Address - State:CA
Mailing Address - Zip Code:93460
Mailing Address - Country:US
Mailing Address - Phone:805-688-7070
Mailing Address - Fax:805-686-2060
Practice Address - Street 1:90 VIA JUANA LANE
Practice Address - Street 2:C/O SANTA YNEZ TRIBAL HEALTH CLINIC
Practice Address - City:SANTA YNEZ
Practice Address - State:CA
Practice Address - Zip Code:93460
Practice Address - Country:US
Practice Address - Phone:805-688-7070
Practice Address - Fax:805-686-2060
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA372570163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse