Provider Demographics
NPI:1326302688
Name:NALLY, MARY ANNE (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:NALLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 BELLEFONTAINE ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2437
Mailing Address - Country:US
Mailing Address - Phone:626-403-1656
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0123
Practice Address - Country:US
Practice Address - Phone:323-226-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN364505163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse