Provider Demographics
NPI:1639119225
Name:LAVERDURE, ADRIENNE (MD)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:LAVERDURE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-9190
Mailing Address - Country:US
Mailing Address - Phone:715-356-8000
Mailing Address - Fax:
Practice Address - Street 1:240 MAPLE ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9190
Practice Address - Country:US
Practice Address - Phone:715-356-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32411800Medicaid
WI32411800Medicaid
WI000964013Medicare PIN