Provider Demographics
NPI:1487629689
Name:ENRIQUE-LOFTON, LAVERNE J (NP)
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:J
Last Name:ENRIQUE-LOFTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 CLIFTON SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-4600
Mailing Address - Country:US
Mailing Address - Phone:678-223-8287
Mailing Address - Fax:
Practice Address - Street 1:690 REDDS CIR SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-6525
Practice Address - Country:US
Practice Address - Phone:404-534-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN111252363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA667281594AMedicaid