Basic Information
| Provider Information | |||||||||
| NPI: | 1710597927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALLY | ||||||||
| FirstName: | LACY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | DNP, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 LANE CREEK TER | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306211174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062068658 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1061 DOWDY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306065700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066217575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2020 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN259405 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208000000X | RN259405 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.