Provider Demographics
NPI:1437839644
Name:LAVELLE, MARY DINETT
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DINETT
Last Name:LAVELLE
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 1:877 MISSION RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-8006
Mailing Address - Country:US
Mailing Address - Phone:510-712-8780
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8251
Practice Address - Country:US
Practice Address - Phone:209-465-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker