Provider Demographics
NPI:1295728566
Name:LAVERY, KATHLEEN A (CNM)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:LAVERY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-1709
Mailing Address - Country:US
Mailing Address - Phone:517-796-1398
Mailing Address - Fax:517-796-8057
Practice Address - Street 1:500 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-1709
Practice Address - Country:US
Practice Address - Phone:517-796-1398
Practice Address - Fax:517-796-8057
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKL183182176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4563623Medicaid
MI4790069Medicaid
MI4790069Medicaid
0P08490Medicare PIN
MI4563623Medicaid