Provider Demographics
NPI:1841286614
Name:GALLOGLY, MELISSA JEAN (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:GALLOGLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 249
Mailing Address - Street 2:1882 NEW SCOTLAND ROAD
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-0249
Mailing Address - Country:US
Mailing Address - Phone:518-689-3588
Mailing Address - Fax:518-689-3597
Practice Address - Street 1:1882 NEW SCOTLAND ROAD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-0249
Practice Address - Country:US
Practice Address - Phone:518-689-3588
Practice Address - Fax:518-689-3597
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333787-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02428926Medicaid
NYP80021Medicare UPIN
NYRA7048Medicare PIN
NY02428926Medicaid