Provider Demographics
NPI:1285706986
Name:GALLARDO, MARISA KATHLEEN (RN)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:KATHLEEN
Last Name:GALLARDO
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 1:25862 JASPER RD APT 3
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-7202
Mailing Address - Country:US
Mailing Address - Phone:415-205-5384
Mailing Address - Fax:
Practice Address - Street 1:MEDDAC 4TH & INNER LOOP
Practice Address - Street 2:
Practice Address - City:FT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-380-3185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622276163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse