Healthcare Provider Details

I. General information

NPI: 1427589746
Provider Name (Legal Business Name): VANESSA LEE RALLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68B ROUTE 6A
SANDWICH MA
02563-1864
US

IV. Provider business mailing address

68B ROUTE 6A
SANDWICH MA
02563-1864
US

V. Phone/Fax

Practice location:
  • Phone: 508-833-0269
  • Fax:
Mailing address:
  • Phone: 508-833-0269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number283959
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier283959
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMEDICAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: