Provider Demographics
NPI:1497224448
Name:MARTIN, LAQUINTA
Entity Type:Individual
Prefix:
First Name:LAQUINTA
Middle Name:
Last Name:MARTIN
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:PO BOX 3324
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-3324
Mailing Address - Country:US
Mailing Address - Phone:276-732-4852
Mailing Address - Fax:276-632-9456
Practice Address - Street 1:930 BROOKDALE ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-3105
Practice Address - Country:US
Practice Address - Phone:276-732-4852
Practice Address - Fax:276-632-9456
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization