Provider Demographics
NPI:1528802899
Name:LAVALLIE, TAMMY RAE
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:RAE
Last Name:LAVALLIE
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 1:1756 35TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-7408
Mailing Address - Country:US
Mailing Address - Phone:701-721-0642
Mailing Address - Fax:
Practice Address - Street 1:1756 35TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7408
Practice Address - Country:US
Practice Address - Phone:701-721-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker