Healthcare Provider Details

I. General information

NPI: 1194906164
Provider Name (Legal Business Name): CRYSTAL CRISTINA GALLARDO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 08/09/2026
Certification Date: 08/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13607 S MENLO AVE
GARDENA CA
90247-2135
US

IV. Provider business mailing address

13607 S MENLO AVE
GARDENA CA
90247-2135
US

V. Phone/Fax

Practice location:
  • Phone: 805-714-4643
  • Fax:
Mailing address:
  • Phone: 805-714-4643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95040538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: