Provider Demographics
NPI:1184184004
Name:LALLY, LINDA LORETTA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:LORETTA
Last Name:LALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 STACK DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1662
Mailing Address - Country:US
Mailing Address - Phone:347-598-6171
Mailing Address - Fax:
Practice Address - Street 1:69 STACK DR
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1662
Practice Address - Country:US
Practice Address - Phone:347-598-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY370379208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice