Provider Demographics
NPI:1629796982
Name:GALLEGOS, MISTY JO (APRN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:JO
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:JO
Other - Last Name:MAPES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1101 LAMBSDOWNE LN
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-8717
Mailing Address - Country:US
Mailing Address - Phone:707-628-5827
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2477
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28152890A390200000X, 163W00000X, 363LP0200X
IN71014809A363LP0200X
IN28152890C163WN0002X
CA604722163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care