Provider Demographics
NPI:1942429618
Name:GALLO, ELIZABETH (RD)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:GALLO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVENUE, STE 400
Mailing Address - Street 2:AKDHC, LLC
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1003 DIVISION ST
Practice Address - Street 2:STE 5
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1657
Practice Address - Country:US
Practice Address - Phone:928-445-7632
Practice Address - Fax:928-445-9283
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ873988133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ218901Medicaid
AZ873988OtherRD LICENSE
AZ115376Medicare PIN