Provider Demographics
NPI:1215901079
Name:LAVIGNE, KATHLEEN M (CRNA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:LAVIGNE
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:PO BOX 6037
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-6037
Mailing Address - Country:US
Mailing Address - Phone:985-873-4235
Mailing Address - Fax:985-851-4307
Practice Address - Street 1:8166 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360
Practice Address - Country:US
Practice Address - Phone:985-873-4141
Practice Address - Fax:985-851-4307
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1922668Medicaid
LA59852Medicare ID - Type Unspecified