Provider Demographics
NPI:1649415845
Name:LAVALLEE, LINDA H (ANP,BC)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:H
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:ANP,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103
Mailing Address - Country:US
Mailing Address - Phone:413-739-1100
Mailing Address - Fax:413-735-1133
Practice Address - Street 1:1049 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:413-735-1133
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA198710363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110028120Medicaid
MAML1390018OtherSTATE CONTROLLED SUBSTANCE REGISTRATION
MAML0622527IOtherSTATE CONTROLLED SUBSTANCE REGISTRATION
MAML0622527IOtherSTATE CONTROLLED SUBSTANCE REGISTRATION
MA110028120Medicaid
MAM21172Medicare PIN