Provider Demographics
NPI:1750124111
Name:GALLAGHER, RYAN T (APN-CNP)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:T
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W LAKE ST STE 301
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2565
Mailing Address - Country:US
Mailing Address - Phone:331-221-1650
Mailing Address - Fax:331-221-2710
Practice Address - Street 1:303 W LAKE ST STE 301
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2565
Practice Address - Country:US
Practice Address - Phone:331-221-1650
Practice Address - Fax:331-221-2710
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029542363LP0808X
IL209029542363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health