Provider Demographics
NPI:1457852451
Name:SHANKS, LAQUANTA DENITRIS
Entity Type:Individual
Prefix:
First Name:LAQUANTA
Middle Name:DENITRIS
Last Name:SHANKS
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 1:4505 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6707
Mailing Address - Country:US
Mailing Address - Phone:904-219-7791
Mailing Address - Fax:
Practice Address - Street 1:4505 GILBERT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-6707
Practice Address - Country:US
Practice Address - Phone:904-219-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82-4168752Medicaid