Provider Demographics
NPI:1427588797
Name:GALLARDO, ICELIND RUBY
Entity type:Individual
Prefix:
First Name:ICELIND
Middle Name:RUBY
Last Name:GALLARDO
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 1:7603 CULEBRA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-1437
Mailing Address - Country:US
Mailing Address - Phone:663-892-7278
Mailing Address - Fax:
Practice Address - Street 1:7603 CULEBRA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1437
Practice Address - Country:US
Practice Address - Phone:663-892-7278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA787387163W00000X
TX1074110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse