Basic Information
| Provider Information | |||||||||
| NPI: | 1336226638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLO | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | CSMCP CLINIC CREDENTIALING | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142704932 | ||||||||
| FaxNumber: | 4142915195 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320 N LAKE DR | ||||||||
| Address2: | SUITE 3603 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142704932 | ||||||||
| FaxNumber: | 4142915195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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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 | 363L00000X | 2127 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43996600 | 05 | WI | MEDICAID |