Provider Demographics
NPI:1598354656
Name:LAVALLIE, JEANETTE
Entity Type:Individual
Prefix:MISS
First Name:JEANETTE
Middle Name:
Last Name:LAVALLIE
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:PO BOX 525
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0525
Mailing Address - Country:US
Mailing Address - Phone:701-314-9950
Mailing Address - Fax:
Practice Address - Street 1:7063 CROWHILL RD
Practice Address - Street 2:
Practice Address - City:OBERON
Practice Address - State:ND
Practice Address - Zip Code:58357-5835
Practice Address - Country:US
Practice Address - Phone:701-314-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care