Basic Information
| Provider Information | |||||||||
| NPI: | 1609192004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NALLY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NALLY | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 PARK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065048901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854081 | ||||||||
| FaxNumber: | 2037377635 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PARK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065048901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854081 | ||||||||
| FaxNumber: | 2037377635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | A125602 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 208000000X | 61675 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.