Provider Demographics
NPI:1497527253
Name:FRAVEL, LANETTE L (MA)
Entity Type:Individual
Prefix:
First Name:LANETTE
Middle Name:L
Last Name:FRAVEL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6913 BLAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1013
Mailing Address - Country:US
Mailing Address - Phone:260-223-2942
Mailing Address - Fax:
Practice Address - Street 1:6913 BLAKE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1013
Practice Address - Country:US
Practice Address - Phone:260-223-2942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health