Provider Demographics
NPI:1174514715
Name:VALLELY, LISA D (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:D
Last Name:VALLELY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1528
Mailing Address - Country:US
Mailing Address - Phone:229-434-2161
Mailing Address - Fax:229-434-2502
Practice Address - Street 1:2000 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1528
Practice Address - Country:US
Practice Address - Phone:229-434-2161
Practice Address - Fax:229-434-2502
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174251367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA466225647AMedicaid
GA43BBBNZMedicare PIN