Provider Demographics
NPI:1336560366
Name:ROE, CHRISTINE GALLARDO (AGPCNP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:GALLARDO
Last Name:ROE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 MEADOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2657
Mailing Address - Country:US
Mailing Address - Phone:248-508-7176
Mailing Address - Fax:
Practice Address - Street 1:33466 W 8 MILE RD
Practice Address - Street 2:SUITE 168
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-5208
Practice Address - Country:US
Practice Address - Phone:248-426-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250488363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704250488OtherNP LICENSE