Provider Demographics
NPI:1730119793
Name:GALLEGOS, ELIZABETH CARBAJAL (NP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:CARBAJAL
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 LA VERNE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6015
Mailing Address - Country:US
Mailing Address - Phone:909-792-7776
Mailing Address - Fax:
Practice Address - Street 1:69175 RAMON RD
Practice Address - Street 2:BUILDING A
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3344
Practice Address - Country:US
Practice Address - Phone:619-344-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303230363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP89401Medicare UPIN
CAZZZ26176ZMedicare PIN