Provider Demographics
NPI:1063881142
Name:GALLIFANT, MIRIAM (OTR/L)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:GALLIFANT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25555 W DURANGO ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-9176
Mailing Address - Country:US
Mailing Address - Phone:623-925-3400
Mailing Address - Fax:
Practice Address - Street 1:25555 W DURANGO ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-9176
Practice Address - Country:US
Practice Address - Phone:623-925-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5095174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist