Provider Demographics
NPI:1235741653
Name:LAVERGNE, KATLYN
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:
Last Name:LAVERGNE
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 1:751 BAYOU PINES EAST DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7196
Mailing Address - Country:US
Mailing Address - Phone:337-433-3292
Mailing Address - Fax:
Practice Address - Street 1:751 BAYOU PINES EAST DR STE C
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7196
Practice Address - Country:US
Practice Address - Phone:337-433-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01148755175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist