Provider Demographics
NPI:1982679676
Name:GALL, ROXANNE B (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:B
Last Name:GALL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 NELSON PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-1742
Mailing Address - Country:US
Mailing Address - Phone:859-578-0442
Mailing Address - Fax:859-578-9113
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:SUITE 394
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-578-0442
Practice Address - Fax:859-578-9113
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4348P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78013620Medicaid
KYQ23312Medicare UPIN
KY1459520Medicare ID - Type UnspecifiedKENTUCKY MEDICARE