Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 125.076399 | IL |
NPI | 1003444894 |
---|---|
Provider Name | Shea Nicole Gallus |
First Address | Oak Lawn, IL 60453-2600 |
Second Address | Oak Lawn, IL 60453-2600 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2020 |
Last Update Date | 14/06/2020 |