Provider Demographics
NPI:1225367790
Name:JELLA, LAVANYA
Entity Type:Individual
Prefix:MRS
First Name:LAVANYA
Middle Name:
Last Name:JELLA
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 1:1050 W SHADY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-5867
Mailing Address - Country:US
Mailing Address - Phone:972-254-0305
Mailing Address - Fax:972-254-3047
Practice Address - Street 1:1050 W SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75060-5867
Practice Address - Country:US
Practice Address - Phone:972-254-0305
Practice Address - Fax:972-254-3047
Is Sole Proprietor?:No
Enumeration Date:2009-12-13
Last Update Date:2009-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist