Provider Demographics
NPI:1508365842
Name:LALLY, KATHLEEN (NP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:LALLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 JACOBSSEN DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6280
Mailing Address - Country:US
Mailing Address - Phone:309-452-0995
Mailing Address - Fax:309-862-0961
Practice Address - Street 1:2010 JACOBSSEN DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6280
Practice Address - Country:US
Practice Address - Phone:309-452-0995
Practice Address - Fax:309-862-0961
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily