Provider Demographics
NPI:1821586207
Name:LAVINE, KRYSTAL KAY
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:KAY
Last Name:LAVINE
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 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:IN
Practice Address - Zip Code:46504-1623
Practice Address - Country:US
Practice Address - Phone:574-335-7850
Practice Address - Fax:574-335-0755
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008330A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102236362OtherANTHEM
IN300020124Medicaid