Provider Demographics
NPI:1891132544
Name:DIXON, LARONDA LYNN
Entity Type:Individual
Prefix:
First Name:LARONDA
Middle Name:LYNN
Last Name:DIXON
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 1:135 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2228
Mailing Address - Country:US
Mailing Address - Phone:318-512-9619
Mailing Address - Fax:318-323-3570
Practice Address - Street 1:135 SHADY LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2228
Practice Address - Country:US
Practice Address - Phone:318-512-9619
Practice Address - Fax:318-323-3570
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1926787Medicaid