Provider Demographics
NPI:1336226638
Name:GALLO, TERESA A (APNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:GALLO
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-270-4932
Mailing Address - Fax:414-291-5195
Practice Address - Street 1:2320 N LAKE DR
Practice Address - Street 2:SUITE 3603
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4507
Practice Address - Country:US
Practice Address - Phone:414-270-4932
Practice Address - Fax:414-291-5195
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2127363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43996600Medicaid
WIP91590Medicare UPIN