Provider Demographics
NPI:1841164605
Name:GALLEGOS, NICOLE D
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 LEWELLING BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-1632
Mailing Address - Country:US
Mailing Address - Phone:341-202-0989
Mailing Address - Fax:
Practice Address - Street 1:268 LEWELLING BLVD
Practice Address - Street 2:
Practice Address - City:SAN LORENZO
Practice Address - State:CA
Practice Address - Zip Code:94580
Practice Address - Country:US
Practice Address - Phone:341-202-0989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA728249164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse