Provider Demographics
NPI:1215312236
Name:LAVALLA, AMY J (DNP, PMHNP-BC, APRN)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:J
Last Name:LAVALLA
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 28TH AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-4420
Mailing Address - Country:US
Mailing Address - Phone:218-512-0630
Mailing Address - Fax:
Practice Address - Street 1:1132 28TH AVE S STE 102
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4420
Practice Address - Country:US
Practice Address - Phone:218-512-0630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR37868363LP0808X
MNCNP 4017363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health