Healthcare Provider Details

I. General information

NPI: 1811081649
Provider Name (Legal Business Name): JONATHAN D LAVERTY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 NEW MOODY LN
LAGRANGE KY
40031-9154
US

IV. Provider business mailing address

1011 HARDIN HOLLY
LAGRANGE KY
40031-8985
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-3886
  • Fax: 502-222-8647
Mailing address:
  • Phone: 502-222-1170
  • Fax: 502-222-8647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1089893
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: