Healthcare Provider Details

I. General information

NPI: 1194772210
Provider Name (Legal Business Name): BONNIE LOU GALLO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CLEARFIELD AVE
VIRGINIA BEACH VA
23462-1815
US

IV. Provider business mailing address

225 CLEARFIELD AVE
VIRGINIA BEACH VA
23462-1815
US

V. Phone/Fax

Practice location:
  • Phone: 757-457-5480
  • Fax: 757-819-7481
Mailing address:
  • Phone: 757-457-5480
  • Fax: 757-819-7481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024107857
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: