Healthcare Provider Details

I. General information

NPI: 1992336192
Provider Name (Legal Business Name): ANTAKEISHA LAVONTE HEPBURN MASTER WIG ARTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANTAKEISHA LAVONTE HEPBURN MASTER WIG ARTIST

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2326 NW 51ST ST
MIAMI FL
33142-3677
US

IV. Provider business mailing address

2326 NW 51ST ST
MIAMI FL
33142-3677
US

V. Phone/Fax

Practice location:
  • Phone: 786-291-7808
  • Fax:
Mailing address:
  • Phone: 786-291-7808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: