Provider Demographics
NPI:1073638284
Name:LAVWAY, AMIE (MT)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:LAVWAY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HANOVER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2971
Mailing Address - Country:US
Mailing Address - Phone:207-773-7788
Mailing Address - Fax:207-773-7711
Practice Address - Street 1:1 CITY CTR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-6420
Practice Address - Country:US
Practice Address - Phone:207-773-7788
Practice Address - Fax:207-773-7711
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3234174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098936OtherANTHEM