Provider Demographics
NPI:1164811394
Name:EDWARDS, LAQUITA
Entity Type:Individual
Prefix:
First Name:LAQUITA
Middle Name:
Last Name:EDWARDS
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 1:636 S RIVER RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4624
Mailing Address - Country:US
Mailing Address - Phone:842-882-2030
Mailing Address - Fax:
Practice Address - Street 1:2555 N DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-372-8080
Practice Address - Fax:414-372-1893
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant