Healthcare Provider Details

I. General information

NPI: 1487381471
Provider Name (Legal Business Name): JERRY E NGALLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date: 09/27/2022
Reactivation Date: 10/04/2022

III. Provider practice location address

721 E FORGE AVE
MESA AZ
85204-4916
US

IV. Provider business mailing address

721 E FORGE AVE
MESA AZ
85204-4916
US

V. Phone/Fax

Practice location:
  • Phone: 602-775-0609
  • Fax: 480-687-5301
Mailing address:
  • Phone: 602-775-0609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: