Provider Demographics
NPI:1073266813
Name:STANLEY, LAQUITA A
Entity Type:Individual
Prefix:
First Name:LAQUITA
Middle Name:A
Last Name:STANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAQUITA
Other - Middle Name:A
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:514 BELLEVUE AVE UNIT 4922
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-7847
Mailing Address - Country:US
Mailing Address - Phone:478-697-4243
Mailing Address - Fax:
Practice Address - Street 1:3487 US HIGHWAY 441 S
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-1229
Practice Address - Country:US
Practice Address - Phone:478-697-4243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009573225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist