Provider Demographics
NPI:1518433606
Name:WARNER, LAQUEENA
Entity Type:Individual
Prefix:
First Name:LAQUEENA
Middle Name:
Last Name:WARNER
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 1:1165 CHESTERDALE DR APT B
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:OH
Mailing Address - Zip Code:45246-2721
Mailing Address - Country:US
Mailing Address - Phone:513-383-0691
Mailing Address - Fax:
Practice Address - Street 1:1165 CHESTERDALE DR APT B
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:OH
Practice Address - Zip Code:45246-2721
Practice Address - Country:US
Practice Address - Phone:513-383-0691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4018778207163104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances