Provider Demographics
NPI:1962257642
Name:GALLIVAN, NATALIE J
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:J
Last Name:GALLIVAN
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 1:28099 W ROCKWELL CT
Mailing Address - Street 2:
Mailing Address - City:LAKEMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60051-6606
Mailing Address - Country:US
Mailing Address - Phone:309-664-7930
Mailing Address - Fax:309-664-7931
Practice Address - Street 1:3002 GILL ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3438
Practice Address - Country:US
Practice Address - Phone:309-664-7930
Practice Address - Fax:309-664-7931
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter