MEDICARE: BENNIE DARAHL GALLEGOS JR. FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	59530	NM

General Provider Information

NPI Number	:	1467086116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENNIE DARAHL GALLEGOS JR. FNP-C

Provider Business Mailing Address
First Line	:	2845 SOLANO DR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-2837
Country	:	US
Telephone Number	:	505-718-8473
Fax Number	:

Provider Business Practice Location Address
First Line	:	2845 SOLANO DR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-2837
Country	:	US
Telephone Number	:	505-718-8473
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2020
Last Update Date	:	06/08/2023

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