Provider Demographics
NPI:1326229550
Name:LAVENDER, KATHERINE REBECCA (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:REBECCA
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7138 S 2000 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3757
Mailing Address - Country:US
Mailing Address - Phone:801-453-9625
Mailing Address - Fax:
Practice Address - Street 1:750 ROUND VALLEY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7548
Practice Address - Country:US
Practice Address - Phone:435-655-0926
Practice Address - Fax:435-649-3748
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6360349-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics