Provider Demographics
NPI:1649558453
Name:LAQUE, TISH ANN (LVN)
Entity Type:Individual
Prefix:
First Name:TISH
Middle Name:ANN
Last Name:LAQUE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 N WESTWOOD AVE
Mailing Address - Street 2:APT # 139
Mailing Address - City:LINDSAY
Mailing Address - State:CA
Mailing Address - Zip Code:93247-1847
Mailing Address - Country:US
Mailing Address - Phone:559-358-0828
Mailing Address - Fax:
Practice Address - Street 1:251 N WESTWOOD AVE
Practice Address - Street 2:APT # 139
Practice Address - City:LINDSAY
Practice Address - State:CA
Practice Address - Zip Code:93247-1847
Practice Address - Country:US
Practice Address - Phone:559-358-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA209693164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse