Provider Demographics
NPI:1710517230
Name:LAVENDER, COURTNEY LEANN
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEANN
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 1:6664 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WILMER
Mailing Address - State:AL
Mailing Address - Zip Code:36587-9536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6664 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:WILMER
Practice Address - State:AL
Practice Address - Zip Code:36587-9536
Practice Address - Country:US
Practice Address - Phone:251-234-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12712390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program