Provider Demographics
NPI:1497104467
Name:JOHNSON, LAQUEENA
Entity Type:Individual
Prefix:
First Name:LAQUEENA
Middle Name:
Last Name:JOHNSON
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 1:10025 W MARKHAM ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-1407
Mailing Address - Country:US
Mailing Address - Phone:501-663-5473
Mailing Address - Fax:501-801-1816
Practice Address - Street 1:10025 W MARKHAM ST
Practice Address - Street 2:SUITE 210
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1407
Practice Address - Country:US
Practice Address - Phone:501-663-5473
Practice Address - Fax:501-801-1816
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator