Provider Demographics
NPI:1982886511
Name:LAVERGNE, KYLE G (NP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:G
Last Name:LAVERGNE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4176
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-4176
Mailing Address - Country:US
Mailing Address - Phone:985-876-0300
Mailing Address - Fax:985-872-0317
Practice Address - Street 1:2730 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5939
Practice Address - Country:US
Practice Address - Phone:337-988-1585
Practice Address - Fax:337-981-4694
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LARN105099 AP05296363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1338109Medicaid
LA332946YJQDMedicare PIN