Provider Demographics
NPI:1366287922
Name:GALLAGHER, ANGELINA (CRNA)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:
Other - Last Name:MAZZULLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:167 DAYTONA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5036
Mailing Address - Country:US
Mailing Address - Phone:386-852-6455
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-5266
Practice Address - Country:US
Practice Address - Phone:352-273-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN425216367500000X
FLAPRN11033751367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123048900Medicaid