Provider Demographics
NPI:1063085017
Name:LAVALLAIS, KELLEY L
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:L
Last Name:LAVALLAIS
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 1:2703 APRIL COVE CT
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-7812
Mailing Address - Country:US
Mailing Address - Phone:713-503-6155
Mailing Address - Fax:
Practice Address - Street 1:1802 STRAWBERRY RD STE C
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77502-2621
Practice Address - Country:US
Practice Address - Phone:713-740-9033
Practice Address - Fax:713-740-9044
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist