Provider Demographics
NPI:1023802204
Name:GALLEGOS, THERESA JEAN
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:JEAN
Last Name:GALLEGOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 CHRIS LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1228
Mailing Address - Country:US
Mailing Address - Phone:928-853-4224
Mailing Address - Fax:
Practice Address - Street 1:6915 CHRIS LN
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1228
Practice Address - Country:US
Practice Address - Phone:928-853-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10168H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility