Provider Demographics
NPI:1932213667
Name:GALLUP, SUSAN JENNIFER (RN,MSN,CPNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JENNIFER
Last Name:GALLUP
Suffix:
Gender:F
Credentials:RN,MSN,CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36000 DARNALL LOOP
Mailing Address - Street 2:NEWBORN CLINIC 2ND FLOOR
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5095
Mailing Address - Country:US
Mailing Address - Phone:254-288-8440
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:NEWBORN CLINIC 2ND FLOOR
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-288-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX612117163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1651853Medicaid
TX1651853Medicaid