Basic Information
| Provider Information | |||||||||
| NPI: | 1720148091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAVALLEE | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | NNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144567000 | ||||||||
| FaxNumber: | 2144560850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144567871 | ||||||||
| FaxNumber: | 2144560850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2006 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | NP124639 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 626130284B | 05 | GA | MEDICAID |