Provider Demographics
NPI:1922103977
Name:LAVANTURE, JACYNDA LEIGH (PA)
Entity Type:Individual
Prefix:
First Name:JACYNDA
Middle Name:LEIGH
Last Name:LAVANTURE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ARCADE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2477
Mailing Address - Country:US
Mailing Address - Phone:574-522-2284
Mailing Address - Fax:574-522-3952
Practice Address - Street 1:500 ARCADE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2477
Practice Address - Country:US
Practice Address - Phone:574-522-2284
Practice Address - Fax:574-522-3952
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000900A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ76379Medicare UPIN
IN184220WMedicare ID - Type Unspecified