Provider Demographics
NPI:1568824407
Name:LOUDER, TAMISHA LAQUINNA
Entity Type:Individual
Prefix:
First Name:TAMISHA
Middle Name:LAQUINNA
Last Name:LOUDER
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 1:1214N COLUMBIA AVENUE UNIT B
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326
Mailing Address - Country:US
Mailing Address - Phone:912-412-4568
Mailing Address - Fax:
Practice Address - Street 1:1214 N COLUMBIA AVE STE B
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-6815
Practice Address - Country:US
Practice Address - Phone:912-412-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-21
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1273061744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management