Provider Demographics
NPI:1902375389
Name:MANUEL, LARONDA LASHA
Entity Type:Individual
Prefix:
First Name:LARONDA
Middle Name:LASHA
Last Name:MANUEL
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 1:2240 TV RD APT 4B
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-3586
Mailing Address - Country:US
Mailing Address - Phone:601-906-6961
Mailing Address - Fax:
Practice Address - Street 1:2240 TV RD APT 4B
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-3586
Practice Address - Country:US
Practice Address - Phone:601-906-6961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800934113172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver