Healthcare Provider Details

I. General information

NPI: 1881228476
Provider Name (Legal Business Name): COLIN LEE GALLIEN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 DOCTORS DR. MEDICAL PLAZA 2
PANAMA CITY FL
32405-4520
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 850-767-2455
  • Fax: 850-767-2790
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11006272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: