Provider Demographics
NPI:1316076334
Name:LAVALLE, VLASTA D (NP)
Entity type:Individual
Prefix:
First Name:VLASTA
Middle Name:D
Last Name:LAVALLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:VLASTA
Other - Middle Name:
Other - Last Name:DOLINAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT, 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6350
Practice Address - Fax:617-629-6067
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258436363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0711594Medicaid
MA000652001Medicare PIN