Provider Demographics
NPI:1003316068
Name:HUMPHRIES, LAVERN
Entity Type:Individual
Prefix:
First Name:LAVERN
Middle Name:
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 HARVEST DR
Mailing Address - Street 2:
Mailing Address - City:NOLANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76559-4732
Mailing Address - Country:US
Mailing Address - Phone:254-931-7140
Mailing Address - Fax:254-931-7140
Practice Address - Street 1:2016 HARVEST DR
Practice Address - Street 2:
Practice Address - City:NOLANVILLE
Practice Address - State:TX
Practice Address - Zip Code:76559-4732
Practice Address - Country:US
Practice Address - Phone:254-931-7140
Practice Address - Fax:254-931-7140
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX836362163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse