Basic Information
| Provider Information | |||||||||
| NPI: | 1538124086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALLI | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | NNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3606 BLUEBONNET CIR | ||||||||
| Address2: | |||||||||
| City: | WEATHERFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760879358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175964477 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1303 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178822892 | ||||||||
| FaxNumber: | 8178825335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | 458242 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
No ID Information.