Provider Demographics
NPI:1518524669
Name:HANKERSON, LAVONDA RUTH
Entity Type:Individual
Prefix:
First Name:LAVONDA
Middle Name:RUTH
Last Name:HANKERSON
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 1:1348 SW 181ST AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-4903
Mailing Address - Country:US
Mailing Address - Phone:786-474-8800
Mailing Address - Fax:
Practice Address - Street 1:20345 W COUNTRY CLUB DR # TH-14
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1631
Practice Address - Country:US
Practice Address - Phone:305-792-4931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL750921Medicaid