=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104778380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LAVALLEY RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2026
-----------------------------------------------------
Last Update Date | 02/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 E 2ND ST
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55805-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-727-8762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4036 LAVAQUE RD
-----------------------------------------------------
City | HERMANTOWN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55811-3668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-390-2813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP2201X
-----------------------------------------------------
Taxonomy Name | Ambulatory Care Registered Nurse
-----------------------------------------------------
License Number | R155130-9
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------