Provider Demographics
NPI:1780120527
Name:GALLAGHER, SHANA
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:CHRISTINE
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-2113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3013
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT100513163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse