Healthcare Provider Details

I. General information

NPI: 1740519487
Provider Name (Legal Business Name): LAURYN ANNE MCNALLY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 JESSUP RD
WEST DEPTFORD NJ
08066-2413
US

IV. Provider business mailing address

600 JESSUP RD
WEST DEPTFORD NJ
08066-2413
US

V. Phone/Fax

Practice location:
  • Phone: 856-845-4061
  • Fax: 856-384-1770
Mailing address:
  • Phone: 856-845-4061
  • Fax: 856-384-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20A11020
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MB09283700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: