Provider Demographics
NPI:1568673259
Name:LAVALLEE, DIANE MCKENNA (NP NURSE PRACTITIONE)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MCKENNA
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:NP NURSE PRACTITIONE
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3112
Mailing Address - Country:US
Mailing Address - Phone:508-771-7284
Mailing Address - Fax:508-771-8655
Practice Address - Street 1:6 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601
Practice Address - Country:US
Practice Address - Phone:508-771-7284
Practice Address - Fax:508-771-8655
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA227349367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP3377OtherBLUE CROSS BLUE SHIELD