Provider Demographics
NPI:1871797977
Name:LAVIA, JENNIFER A (APNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:LAVIA
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:RAJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-3200
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:130 2ND ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-729-2738
Practice Address - Fax:920-729-3021
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152277364S00000X
WI3111363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI711290026OtherMEDICARE PTAN