Provider Demographics
NPI:1821532243
Name:LLANOS, LAWANZA
Entity Type:Individual
Prefix:
First Name:LAWANZA
Middle Name:
Last Name:LLANOS
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 1:1911 E 143RD AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2536
Mailing Address - Country:US
Mailing Address - Phone:813-562-3555
Mailing Address - Fax:813-252-6006
Practice Address - Street 1:1911 E 143RD AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2536
Practice Address - Country:US
Practice Address - Phone:813-562-3555
Practice Address - Fax:813-252-6006
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906889311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home