Provider Demographics
NPI:1457898793
Name:SMITH, LAQUITA JO (LPN)
Entity Type:Individual
Prefix:
First Name:LAQUITA
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5864 HOLCOMB ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3091
Mailing Address - Country:US
Mailing Address - Phone:313-758-8122
Mailing Address - Fax:
Practice Address - Street 1:5864 HOLCOMB ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3091
Practice Address - Country:US
Practice Address - Phone:313-758-8122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703056770164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703056770OtherLPN