Provider Demographics
NPI:1730856204
Name:LASSALLE, MALLORY (NNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:
Last Name:LASSALLE
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:LEBLANC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:833 ROSA AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-2127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5798
Practice Address - Country:US
Practice Address - Phone:504-896-9418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA221800363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal