Provider Demographics
NPI:1700831468
Name:KENNEALLY, GAILA MAUREEN (DO)
Entity Type:Individual
Prefix:DR
First Name:GAILA
Middle Name:MAUREEN
Last Name:KENNEALLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GAILA
Other - Middle Name:
Other - Last Name:TRICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:535 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101-4114
Mailing Address - Country:US
Mailing Address - Phone:530-233-2288
Mailing Address - Fax:
Practice Address - Street 1:601 UNIVERSITY DR
Practice Address - Street 2:STUDENT HEALTH CENTER
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-4684
Practice Address - Country:US
Practice Address - Phone:512-245-2161
Practice Address - Fax:512-245-9288
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196414002Medicaid
TX196414001Medicaid
TX8L1076Medicare PIN
TX8L1078Medicare PIN
I50483Medicare UPIN
TX8G4220Medicare PIN