Healthcare Provider Details

I. General information

NPI: 1790891323
Provider Name (Legal Business Name): CAROL W GALLAGHER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE
FARMINGTON CT
06030
US

IV. Provider business mailing address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2160
  • Fax: 860-679-1422
Mailing address:
  • Phone: 860-679-2160
  • Fax: 860-679-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number002146
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number002146
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number002146
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: