Healthcare Provider Details

I. General information

NPI: 1013756808
Provider Name (Legal Business Name): TARYLL GALLOWAY FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 W GLENDALE AVE STE 32A
PHOENIX AZ
85051-8485
US

IV. Provider business mailing address

18828 W JEFFERSON ST
BUCKEYE AZ
85326-6345
US

V. Phone/Fax

Practice location:
  • Phone: 602-246-7462
  • Fax:
Mailing address:
  • Phone: 602-884-4080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number307626
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: