Healthcare Provider Details

I. General information

NPI: 1750124111
Provider Name (Legal Business Name): RYAN T GALLAGHER APN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W LAKE ST STE 301
ADDISON IL
60101-2565
US

IV. Provider business mailing address

303 W LAKE ST STE 301
ADDISON IL
60101-2565
US

V. Phone/Fax

Practice location:
  • Phone: 331-221-1650
  • Fax: 331-221-2710
Mailing address:
  • Phone: 331-221-1650
  • Fax: 331-221-2710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209029542
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.029542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: