=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720536543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY GALLAGHER AG-ACNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2016
-----------------------------------------------------
Last Update Date | 09/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44195-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-407-7046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5804 PARK RIDGE DR
-----------------------------------------------------
City | NORTH OLMSTED
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44070-4137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-476-4577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | RN.366982
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------