1467538223 NPI number — MRS. GABRIELE M. LALLY PA-C

Table of content: MRS. GABRIELE M. LALLY PA-C (NPI 1467538223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467538223 NPI number — MRS. GABRIELE M. LALLY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LALLY
Provider First Name:
GABRIELE
Provider Middle Name:
M.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467538223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 MARTIN LUTHER KING JR WAY
Provider Second Line Business Mailing Address:
3 PHILIP PAVILION
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-403-2633
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1708 YAKIMA AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-5307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-426-4420
Provider Business Practice Location Address Fax Number:
253-426-4383
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA10004845 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8431595 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0259143 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 335060 . This is a "INTERNAL ID-MOTOR VEHICLE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20110221364696 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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