Provider Demographics
NPI:1871564245
Name:LALLY, PATRICIA E (DO MPH)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:LALLY
Suffix:
Gender:F
Credentials:DO MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 KANAWHA AVE
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1013
Mailing Address - Country:US
Mailing Address - Phone:304-438-6188
Mailing Address - Fax:304-438-4037
Practice Address - Street 1:645 KANAWHA AVE
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1013
Practice Address - Country:US
Practice Address - Phone:304-438-6188
Practice Address - Fax:304-438-4037
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1529208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5336168OtherAETNA
WV0110398000Medicaid
WV1719217OtherBC/BS
WVP00067677OtherRR MEDICARE
WVP99827OtherTRICARE
WV5336168OtherAETNA
WV1719217OtherBC/BS