Healthcare Provider Details

I. General information

NPI: 1932213667
Provider Name (Legal Business Name): SUSAN JENNIFER GALLUP RN,MSN,CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36000 DARNALL LOOP NEWBORN CLINIC 2ND FLOOR
FORT HOOD TX
76544-5095
US

IV. Provider business mailing address

36000 DARNALL LOOP NEWBORN CLINIC 2ND FLOOR
FORT HOOD TX
76544-5095
US

V. Phone/Fax

Practice location:
  • Phone: 254-288-8440
  • Fax:
Mailing address:
  • Phone: 254-288-8440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number612117
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: