Provider Demographics
NPI:1083878540
Name:IDIAQUEZ, TONI JANELL (LAC)
Entity Type:Individual
Prefix:MRS
First Name:TONI
Middle Name:JANELL
Last Name:IDIAQUEZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:J3
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6323
Mailing Address - Country:US
Mailing Address - Phone:770-313-0106
Mailing Address - Fax:404-474-7031
Practice Address - Street 1:328 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3235
Practice Address - Country:US
Practice Address - Phone:770-313-0106
Practice Address - Fax:404-474-7031
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000063171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist