Healthcare Provider Details

I. General information

NPI: 1235092503
Provider Name (Legal Business Name): GRISELDA GALLAGHER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 N MAIN ST NW
CONYERS GA
30012-4352
US

IV. Provider business mailing address

140 MARBROOK TRCE
OXFORD GA
30054-2746
US

V. Phone/Fax

Practice location:
  • Phone: 770-761-8889
  • Fax: 770-761-0855
Mailing address:
  • Phone: 770-761-8889
  • Fax: 770-761-0855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN253985
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: