Provider Demographics
NPI:1578380887
Name:SMART-GALLEGOS, KENEISIA (RN)
Entity type:Individual
Prefix:
First Name:KENEISIA
Middle Name:
Last Name:SMART-GALLEGOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0131
Mailing Address - Country:US
Mailing Address - Phone:619-920-2665
Mailing Address - Fax:
Practice Address - Street 1:3475 N SARATOGA ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278-4927
Practice Address - Country:US
Practice Address - Phone:360-929-0489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61277119163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse