Provider Demographics
NPI:1407453277
Name:CALLAHAN, PRINCESS LAQA
Entity Type:Individual
Prefix:MS
First Name:PRINCESS
Middle Name:LAQA
Last Name:CALLAHAN
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 1:609 SW 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-1346
Mailing Address - Country:US
Mailing Address - Phone:786-955-4239
Mailing Address - Fax:
Practice Address - Street 1:2620 NW 19TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-3324
Practice Address - Country:US
Practice Address - Phone:786-659-2598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor