Basic Information
| Provider Information | |||||||||
| NPI: | 1083815005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMALLEY | ||||||||
| FirstName: | GWEN | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 ACACIA RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949301502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154590337 | ||||||||
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| Practice Location | |||||||||
| Address1: | 361 3RD ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949013541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155074030 | ||||||||
| FaxNumber: | 4155072634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0101X | 278604 | CA | Y | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory |
No ID Information.