Healthcare Provider Details

I. General information

NPI: 1326048174
Provider Name (Legal Business Name): JENNIFER LUCY AVEGNO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 INDUSTRIAL BLVD
HARVEY LA
70058-2314
US

IV. Provider business mailing address

1816 INDUSTRIAL BLVD
HARVEY LA
70058-2314
US

V. Phone/Fax

Practice location:
  • Phone: 504-366-7638
  • Fax:
Mailing address:
  • Phone: 504-366-7638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25601
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: