Provider Demographics
NPI:1902202872
Name:GALLO, DOMINIQUE S (BS, IBCLC, RLC)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:S
Last Name:GALLO
Suffix:
Gender:F
Credentials:BS, IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 BERRYHILL DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4403
Mailing Address - Country:US
Mailing Address - Phone:757-598-2507
Mailing Address - Fax:540-444-2309
Practice Address - Street 1:3537 BERRYHILL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4403
Practice Address - Country:US
Practice Address - Phone:757-598-2507
Practice Address - Fax:540-444-2309
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
VAL-6071174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN