Provider Demographics
NPI:1407205347
Name:GALLUP, ASHLEY
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:GALLUP
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 1:2817 SE 91ST ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-9123
Mailing Address - Country:US
Mailing Address - Phone:405-371-5729
Mailing Address - Fax:
Practice Address - Street 1:2817 SE 91ST ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-9123
Practice Address - Country:US
Practice Address - Phone:405-371-5729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0101320163WC0200X
OK101320367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine