Provider Demographics
NPI:1487494654
Name:LALLY, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LALLY
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 1:12400 MONTECITO RD APT 401
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-2736
Mailing Address - Country:US
Mailing Address - Phone:562-480-3119
Mailing Address - Fax:
Practice Address - Street 1:12400 MONTECITO RD APT 401
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-2736
Practice Address - Country:US
Practice Address - Phone:562-480-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA802855163WC0400X, 163WC1500X, 163WL0100X, 163WM0102X, 163WN0003X, 163WP0808X, 163WP1700X, 163WX0002X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP1700XNursing Service ProvidersRegistered NursePerinatal
No163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk