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NPI Code Detail

MEDICARE: LAQUANN WALLACE

MEDICARE: LAQUANN WALLACE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
13747P1801XPersonal Care Attendant

General Provider Information

NPI Number : 1124580873
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAQUANN WALLACE
Provider Business Mailing Address
First Line : 2235 E FLAMINGO RD STE 130
Second Line :
City : LAS VEGAS
State : NV
Zip : 89119-5189
Country : US
Telephone Number : 702-890-0405
Fax Number :
Provider Business Practice Location Address
First Line : 2235 E FLAMINGO RD STE 130
Second Line :
City : LAS VEGAS
State : NV
Zip : 89119-5189
Country : US
Telephone Number : 702-890-0405
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/02/2019
Last Update Date : 01/10/2022

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Directions to “ LAQUANN WALLACE ” Practice Location

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