Healthcare Provider Details

I. General information

NPI: 1689594707
Provider Name (Legal Business Name): LISA M GALLEGOS RN53925
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2026
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LEGION DR
LAS VEGAS NM
87701-4804
US

IV. Provider business mailing address

304 PECOS ST
LAS VEGAS NM
87701-6440
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-3515
  • Fax:
Mailing address:
  • Phone: 575-512-5011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number53925
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: