Provider Demographics
NPI:1841511342
Name:LALLEY-DEMONG, VANESSA (DO)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:LALLEY-DEMONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:LALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 1D CREDENTIALING
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-744-1865
Mailing Address - Fax:315-744-1954
Practice Address - Street 1:4000 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6635
Practice Address - Country:US
Practice Address - Phone:315-663-0059
Practice Address - Fax:315-663-0123
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY275026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03950429Medicaid