Healthcare Provider Details

I. General information

NPI: 1154632347
Provider Name (Legal Business Name): MARISSA GALLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

38935 ANN ARBOR RD
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-5770
  • Fax:
Mailing address:
  • Phone: 734-632-0175
  • Fax: 734-632-0182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704274708
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: