Provider Demographics
NPI:1750696605
Name:GALLEGOS, MARY LEE (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:4001 N COOK ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-5879
Practice Address - Country:US
Practice Address - Phone:509-483-3427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60161493363LF0000X
IDNP-990A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily