Healthcare Provider Details

I. General information

NPI: 1104609932
Provider Name (Legal Business Name): VIRTUALMED PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 E BASELINE RD STE 101
MESA AZ
85206-4413
US

IV. Provider business mailing address

PO BOX 51504
MESA AZ
85208-0076
US

V. Phone/Fax

Practice location:
  • Phone: 480-603-8859
  • Fax:
Mailing address:
  • Phone: 480-603-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MIANNA GALE
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 480-603-8859