Provider Demographics
NPI:1215481650
Name:LALLY, AUDREY (MS, RDN, CDE)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:LALLY
Suffix:
Gender:F
Credentials:MS, RDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 E LYNWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2309 E LYNWOOD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-2229
Practice Address - Country:US
Practice Address - Phone:480-593-9348
Practice Address - Fax:480-834-4405
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-14
Last Update Date:2016-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
68870Medicare PIN