Healthcare Provider Details

I. General information

NPI: 1295663516
Provider Name (Legal Business Name): LAQUISHA REESE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

948 TYRELL DR
AUSTELL GA
30106-1552
US

IV. Provider business mailing address

948 TYRELL DR
AUSTELL GA
30106-1552
US

V. Phone/Fax

Practice location:
  • Phone: 678-315-3626
  • Fax:
Mailing address:
  • Phone: 678-315-3626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number415207301
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: