Healthcare Provider Details

I. General information

NPI: 1164090767
Provider Name (Legal Business Name): STACIAN GALLIMORE-KING NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 EASTCHESTER RD
BRONX NY
10461-2374
US

IV. Provider business mailing address

3044 ELY AVE
BRONX NY
10469-3227
US

V. Phone/Fax

Practice location:
  • Phone: 718-405-8505
  • Fax:
Mailing address:
  • Phone: 718-924-1601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0516845
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: