Provider Demographics
NPI:1609297050
Name:ROBERTSON, LAQUANDRA (LPN)
Entity Type:Individual
Prefix:MS
First Name:LAQUANDRA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19746 TRACEY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1527
Mailing Address - Country:US
Mailing Address - Phone:586-350-6460
Mailing Address - Fax:313-557-9779
Practice Address - Street 1:19746 TRACEY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1527
Practice Address - Country:US
Practice Address - Phone:586-350-6460
Practice Address - Fax:313-557-9779
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-01
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703109582164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse