Provider Demographics
NPI:1003375585
Name:JOHNSON, LAQUNDA
Entity Type:Individual
Prefix:
First Name:LAQUNDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2538 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34946-1715
Mailing Address - Country:US
Mailing Address - Phone:772-475-2263
Mailing Address - Fax:
Practice Address - Street 1:2330 SAINT LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34946-6724
Practice Address - Country:US
Practice Address - Phone:772-475-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide