Provider Demographics
NPI:1467882530
Name:DAUGHERTY-SOUTHER, LAVAWN (LPN, IBCLC)
Entity Type:Individual
Prefix:
First Name:LAVAWN
Middle Name:
Last Name:DAUGHERTY-SOUTHER
Suffix:
Gender:F
Credentials:LPN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W BURRELL DR
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8898
Mailing Address - Country:US
Mailing Address - Phone:219-663-9913
Mailing Address - Fax:219-663-9923
Practice Address - Street 1:800 W BURRELL DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8898
Practice Address - Country:US
Practice Address - Phone:219-663-9913
Practice Address - Fax:219-663-9923
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
IN27047986A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No164W00000XNursing Service ProvidersLicensed Practical Nurse