Provider Demographics
NPI:1790010528
Name:LAVENDER, LARRY ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ALAN
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PRESTWICK LOOP NW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-7789
Mailing Address - Country:US
Mailing Address - Phone:678-721-9981
Mailing Address - Fax:
Practice Address - Street 1:304 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5621
Practice Address - Country:US
Practice Address - Phone:706-291-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170718367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered