Provider Demographics
NPI:1841542172
Name:MIESSE, LAVONNA
Entity type:Individual
Prefix:
First Name:LAVONNA
Middle Name:
Last Name:MIESSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAVONNA
Other - Middle Name:
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2708 GRANDVIEW DR W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-2619
Mailing Address - Country:US
Mailing Address - Phone:253-566-5620
Mailing Address - Fax:
Practice Address - Street 1:2708 GRANDVIEW DR W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-2619
Practice Address - Country:US
Practice Address - Phone:253-566-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker