Provider Demographics
NPI:1700831468
Name:KENNEALLY, GAILA MAUREEN (DO)
Entity type:Individual
Prefix:DR
First Name:GAILA
Middle Name:MAUREEN
Last Name:KENNEALLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GAILA
Other - Middle Name:
Other - Last Name:TRICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3170 GLENMANOR PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1713
Mailing Address - Country:US
Mailing Address - Phone:512-736-0313
Mailing Address - Fax:
Practice Address - Street 1:3921 W SUNSET BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2241
Practice Address - Country:US
Practice Address - Phone:646-650-5337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A18171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196414002Medicaid
TX196414001Medicaid
TX8L1076Medicare PIN
TX8L1078Medicare PIN
I50483Medicare UPIN
TX8G4220Medicare PIN