Healthcare Provider Details

I. General information

NPI: 1053733857
Provider Name (Legal Business Name): KATELINE LAVACHE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PROMENADE II 1230 PEACHTREE ST NE 19TH FLOOR
ATLANTA GA
30309-3574
US

IV. Provider business mailing address

40 S MAIN ST STE 1300
MEMPHIS TN
38103-5513
US

V. Phone/Fax

Practice location:
  • Phone: 866-949-0108
  • Fax:
Mailing address:
  • Phone: 866-949-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number477562-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9197326
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN291455
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: