Healthcare Provider Details

I. General information

NPI: 1306408786
Provider Name (Legal Business Name): ELIZABETH GALLEGOS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 819 BOX 4610
FPO AE
09645-0047
US

IV. Provider business mailing address

PSC 819 BOX 4610
FPO AE
09645-0047
US

V. Phone/Fax

Practice location:
  • Phone: 860-324-6108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number122969
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: