Provider Demographics
NPI:1730266602
Name:EDDY, LAVONNE (NP)
Entity type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:EDDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W OLD KEY DR
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-9057
Mailing Address - Country:US
Mailing Address - Phone:765-475-6963
Mailing Address - Fax:765-475-2833
Practice Address - Street 1:315 W OLD KEY DR
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-9057
Practice Address - Country:US
Practice Address - Phone:765-475-6963
Practice Address - Fax:765-475-2833
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200375930Medicaid
500012732Medicare PIN
IN151560J6Medicare PIN
500012732Medicare PIN
IN200375930Medicaid