Provider Demographics
NPI:1215240700
Name:GALLANT-ROMAN, MARY ALICE (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:GALLANT-ROMAN
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 1:1 TAMPA GENERAL CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3571
Mailing Address - Country:US
Mailing Address - Phone:813-844-8523
Mailing Address - Fax:813-844-8047
Practice Address - Street 1:1 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-8523
Practice Address - Fax:813-844-8047
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3286052363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023857700Medicaid
FLDG1O5OtherBLUE CROSS BLUE SHIELD