MEDICARE: MS. MARY EDITH GALVIN RNC FNP PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	CA207865	CA

General Provider Information

NPI Number	:	1619967395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY EDITH GALVIN RNC FNP PHD

Provider Business Mailing Address
First Line	:	PO BOX 2793
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352
Country	:	US
Telephone Number	:	909-336-4997
Fax Number	:

Provider Business Practice Location Address
First Line	:	29011 HOSPITAL RD
Second Line	:	STE 200
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352
Country	:	US
Telephone Number	:	909-336-9715
Fax Number	:	909-336-5751

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	07/08/2007

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