Healthcare Provider Details

I. General information

NPI: 1508365842
Provider Name (Legal Business Name): KATHLEEN LALLY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 JACOBSSEN DR
NORMAL IL
61761-6280
US

IV. Provider business mailing address

2010 JACOBSSEN DR
NORMAL IL
61761-6280
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-0995
  • Fax: 309-862-0961
Mailing address:
  • Phone: 309-452-0995
  • Fax: 309-862-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: