Provider Demographics
NPI:1790448280
Name:GALLEGO, JENA NICOLE (NP)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:NICOLE
Last Name:GALLEGO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENA
Other - Middle Name:NICOLE
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:541 BUTTERMILK PIKE STE 100
Mailing Address - Street 2:
Mailing Address - City:CRESCENT SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1689
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:541 BUTTERMILK PIKE STE 100
Practice Address - Street 2:
Practice Address - City:CRESCENT SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:41017-1689
Practice Address - Country:US
Practice Address - Phone:859-212-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH379209163WG0000X
KY3016939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice