Provider Demographics
NPI:1083815005
Name:OMALLEY, GWEN (RN)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:OMALLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 ACACIA RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1502
Mailing Address - Country:US
Mailing Address - Phone:415-459-0337
Mailing Address - Fax:
Practice Address - Street 1:361 3RD ST
Practice Address - Street 2:SUITE E
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3541
Practice Address - Country:US
Practice Address - Phone:415-507-4030
Practice Address - Fax:415-507-2634
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA278604163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory