Provider Demographics
NPI:1457723488
Name:LALLY, MICHELLE MEROLA (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MEROLA
Last Name:LALLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:MEROLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-638-2515
Mailing Address - Fax:252-638-8538
Practice Address - Street 1:3110 WELLONS BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5247
Practice Address - Country:US
Practice Address - Phone:252-638-2515
Practice Address - Fax:252-638-8538
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005127363A00000X
DCPA031196363A00000X
NC0010-12997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant