Provider Demographics
NPI:1194767327
Name:GALLAWAY, JENNIFER GAIL (ARNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GAIL
Last Name:GALLAWAY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4350
Mailing Address - Country:US
Mailing Address - Phone:405-533-1332
Mailing Address - Fax:405-533-1704
Practice Address - Street 1:821 S PINE ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4350
Practice Address - Country:US
Practice Address - Phone:405-533-1332
Practice Address - Fax:405-533-1704
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0073110207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200057450AMedicaid
OK730929415001OtherBCBS OF OKLAHOMA
OH110236658OtherRAILROAD MEDICARE
OK730929415001OtherBCBS OF OKLAHOMA
OKQ42093Medicare UPIN