Provider Demographics
NPI:1942216098
Name:GALLETTA, MARIE JEAN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:JEAN
Last Name:GALLETTA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 DURGES ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4204
Mailing Address - Country:US
Mailing Address - Phone:718-667-7134
Mailing Address - Fax:718-667-7134
Practice Address - Street 1:1145 TARGEE ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4323
Practice Address - Country:US
Practice Address - Phone:718-668-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000877-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01992323Medicaid