Healthcare Provider Details

I. General information

NPI: 1407205347
Provider Name (Legal Business Name): ASHLEY GALLUP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 SE 91ST ST
MOORE OK
73160-9123
US

IV. Provider business mailing address

2817 SE 91ST ST
MOORE OK
73160-9123
US

V. Phone/Fax

Practice location:
  • Phone: 405-371-5729
  • Fax:
Mailing address:
  • Phone: 405-371-5729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR0101320
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101320
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: