Healthcare Provider Details

I. General information

NPI: 1871564245
Provider Name (Legal Business Name): PATRICIA E LALLY DO MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 KANAWHA AVE
RAINELLE WV
25962-1013
US

IV. Provider business mailing address

645 KANAWHA AVE
RAINELLE WV
25962-1013
US

V. Phone/Fax

Practice location:
  • Phone: 304-438-6188
  • Fax: 304-438-4037
Mailing address:
  • Phone: 304-438-6188
  • Fax: 304-438-4037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1529
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: