Provider Demographics
NPI:1740787621
Name:LAVENDER, ATHENA T
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:T
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 1:44450 PINETREE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-3869
Mailing Address - Country:US
Mailing Address - Phone:734-207-8316
Mailing Address - Fax:
Practice Address - Street 1:19905 WASHTENAW ST
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-2225
Practice Address - Country:US
Practice Address - Phone:313-778-4290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703098328164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse