Healthcare Provider Details

I. General information

NPI: 1669201166
Provider Name (Legal Business Name): LAQUANZA A JETER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 09/29/2026
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 WILKINSON BLVD
CHARLOTTE NC
28208-5539
US

IV. Provider business mailing address

4117 WELLING AVE
CHARLOTTE NC
28208-2114
US

V. Phone/Fax

Practice location:
  • Phone: 704-617-4050
  • Fax: 704-733-9299
Mailing address:
  • Phone: 704-712-4096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: