Provider Demographics
NPI:1104271030
Name:GALLAGHER, CAITLYN MOONEYHAM
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MOONEYHAM
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 WAKE FOREST RD STE 310
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7376
Mailing Address - Country:US
Mailing Address - Phone:919-862-5620
Mailing Address - Fax:
Practice Address - Street 1:3480 WAKE FOREST RD STE 310
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7376
Practice Address - Country:US
Practice Address - Phone:919-862-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC266220163WP0200X
NC5008525363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics