Provider Demographics
NPI:1770220329
Name:LASALLE, TANQUILA QUENE
Entity Type:Individual
Prefix:
First Name:TANQUILA
Middle Name:QUENE
Last Name:LASALLE
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 1:2601 HODGES ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7311
Mailing Address - Country:US
Mailing Address - Phone:337-439-5628
Mailing Address - Fax:
Practice Address - Street 1:2601 HODGES ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7311
Practice Address - Country:US
Practice Address - Phone:337-439-5628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL1426005261744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA850700187Medicaid