Provider Demographics
NPI:1841624673
Name:FENDERSON, LAVERNE ANNETTA
Entity type:Individual
Prefix:
First Name:LAVERNE
Middle Name:ANNETTA
Last Name:FENDERSON
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 1:351 CHATTERLY LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-5335
Mailing Address - Country:US
Mailing Address - Phone:614-398-6151
Mailing Address - Fax:
Practice Address - Street 1:351 CHATTERLY LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-5335
Practice Address - Country:US
Practice Address - Phone:614-398-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376JOOOOOX-HOMEMAKER376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2720416Medicaid