Healthcare Provider Details

I. General information

NPI: 1821532243
Provider Name (Legal Business Name): LAWANZA LLANOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 E 143RD AVE
TAMPA FL
33613-2536
US

IV. Provider business mailing address

1911 E 143RD AVE
TAMPA FL
33613-2536
US

V. Phone/Fax

Practice location:
  • Phone: 813-562-3555
  • Fax: 813-252-6006
Mailing address:
  • Phone: 813-562-3555
  • Fax: 813-252-6006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number6906889
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: