Healthcare Provider Details

I. General information

NPI: 1043040181
Provider Name (Legal Business Name): LALA MAMMADOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PLAIN ST
PROVIDENCE RI
02903-4816
US

IV. Provider business mailing address

106 E MANNING ST
PROVIDENCE RI
02906-4332
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8100
  • Fax:
Mailing address:
  • Phone: 401-259-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberLP06439
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: