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General NPI Number Information
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NPI Number | 1063264034
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Entity Type | Individual
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Provider Name | BROOKE LALLY OD
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Gender | Female
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Dates
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Enumeration Date | 04/03/2024
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Last Update Date | 08/04/2025
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Provider Practice Location Address
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Address Line | 712 FORTINO BLVD
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City | PUEBLO
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State | CO
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Zip | 81008-2084
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Country | US
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Telephone | 719-542-0236
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Fax |
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Provider Business Mailing Address
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Address Line | 712 FORTINO BLVD
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City | PUEBLO
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State | CO
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Zip | 81008-2084
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2025023993
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0004130
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License Number State | CO
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