Healthcare Provider Details

I. General information

NPI: 1194384420
Provider Name (Legal Business Name): LASONYA L WADE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 GEORGIA AVE APT D21
WEST PALM BEACH FL
33405-1467
US

IV. Provider business mailing address

2800 GEORGIA AVE APT D21
WEST PALM BEACH FL
33405-1467
US

V. Phone/Fax

Practice location:
  • Phone: 305-850-0788
  • Fax:
Mailing address:
  • Phone: 305-850-0788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5232003
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: