1912483744 NPI number — DONNISHA LAVIGNE LAPC

Table of content: DONNISHA LAVIGNE LAPC (NPI 1912483744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912483744 NPI number — DONNISHA LAVIGNE LAPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAVIGNE
Provider First Name:
DONNISHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912483744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545 BROAD ST # 80742
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30341-2259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-395-4965
Provider Business Mailing Address Fax Number:
847-953-0134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 SUN VALLEY DR STE L3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-5630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-395-4965
Provider Business Practice Location Address Fax Number:
847-953-0134
Provider Enumeration Date:
07/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  APC006346 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003180234A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".