Provider Demographics
NPI:1164911467
Name:WILLIAMS, LAQUANDRA SHANTEE (STNA)
Entity Type:Individual
Prefix:
First Name:LAQUANDRA
Middle Name:SHANTEE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2939
Mailing Address - Country:US
Mailing Address - Phone:614-373-2856
Mailing Address - Fax:
Practice Address - Street 1:1138 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2939
Practice Address - Country:US
Practice Address - Phone:614-373-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DTI.0053662472R0900X
OH400508605376K00000X
OH02597433747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0259743Medicaid