Provider Demographics
NPI:1245706720
Name:GALLAGHER, RENAH ELIZABETH (CSFA)
Entity type:Individual
Prefix:
First Name:RENAH
Middle Name:ELIZABETH
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 HAWKINS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-5416
Mailing Address - Country:US
Mailing Address - Phone:706-870-1395
Mailing Address - Fax:
Practice Address - Street 1:780 HAWKINS CREEK DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-5416
Practice Address - Country:US
Practice Address - Phone:706-870-1395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA057038723OtherDRIVERS LICENSE