Provider Demographics
NPI:1649239187
Name:LALLY, KATHERINE MARIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:LALLY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:MARIE
Other - Last Name:PUDLOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:845 N NEW BALLAS CT FL 2
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7134
Mailing Address - Country:US
Mailing Address - Phone:314-983-4700
Mailing Address - Fax:314-567-7520
Practice Address - Street 1:845 N NEW BALLAS CT FL 2
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7134
Practice Address - Country:US
Practice Address - Phone:314-983-4700
Practice Address - Fax:314-567-7520
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant