Provider Demographics
NPI:1659633550
Name:CANCINO GALLAGHER, MARY ANGELA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANGELA
Middle Name:
Last Name:CANCINO GALLAGHER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MARY ANGELA
Other - Middle Name:CANCINO
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:304 N RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4639
Mailing Address - Country:US
Mailing Address - Phone:575-578-0069
Mailing Address - Fax:575-578-0124
Practice Address - Street 1:304 N RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4639
Practice Address - Country:US
Practice Address - Phone:575-578-0069
Practice Address - Fax:575-578-0124
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2927261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine