Provider Demographics
NPI:1710597927
Name:LALLY, LACY ELIZABETH (DNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:ELIZABETH
Last Name:LALLY
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 LANE CREEK TER
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:GA
Mailing Address - Zip Code:30621-1174
Mailing Address - Country:US
Mailing Address - Phone:706-206-8658
Mailing Address - Fax:
Practice Address - Street 1:1061 DOWDY RD STE 101
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5700
Practice Address - Country:US
Practice Address - Phone:706-621-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259405363L00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208000000XAllopathic & Osteopathic PhysiciansPediatrics