Basic Information
| Provider Information | |||||||||
| NPI: | 1932374014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLAGHER | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GALLAGHER | ||||||||
| OtherFirstName: | JENNI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2903 CAPE HORN CIR | ||||||||
| Address2: | |||||||||
| City: | PLATTSMOUTH | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680487159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076901901 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1110 GRUNDMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | NEBRASKA CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 684103397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029731340 | ||||||||
| FaxNumber: | 4028749077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AK 1353 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R853694 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 112020 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | OO871814 | 05 | MS | MEDICAID |