Healthcare Provider Details

I. General information

NPI: 1174779805
Provider Name (Legal Business Name): SANDRA LYNN GALLES APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S PARK ST
MADISON WI
53715-1507
US

IV. Provider business mailing address

1634 KINGS MILL WAY #305
MADISON WI
53718-8007
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-6812
  • Fax: 608-417-6383
Mailing address:
  • Phone: 608-417-6812
  • Fax: 608-417-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number3449-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: