Provider Demographics
NPI:1558734814
Name:LAVENDER, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LAVENDER
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 1:2041 FAIRPORT AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3416
Mailing Address - Country:US
Mailing Address - Phone:513-501-6503
Mailing Address - Fax:
Practice Address - Street 1:2041 FAIRPORT AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3416
Practice Address - Country:US
Practice Address - Phone:513-501-6503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH371943240294376K00000X
OH371943240204163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No163WH0200XNursing Service ProvidersRegistered NurseHome Health