=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336792829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACIELA TERESITA GALLO RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2019
-----------------------------------------------------
Last Update Date | 11/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 CHILDRENS WAY
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-697-3600
-----------------------------------------------------
Fax | 904-697-3601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10140 CENTURION PKWY N
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-697-4000
-----------------------------------------------------
Fax | 904-697-5102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0402X
-----------------------------------------------------
Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
-----------------------------------------------------
License Number | RN9335226
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN9335226
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN11004910
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------