Provider Demographics
NPI:1649898818
Name:WARDELL, MARKEISHA LAQUITA
Entity type:Individual
Prefix:
First Name:MARKEISHA
Middle Name:LAQUITA
Last Name:WARDELL
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 1:3684 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-2553
Mailing Address - Country:US
Mailing Address - Phone:931-591-8501
Mailing Address - Fax:
Practice Address - Street 1:1502 TINY TOWN RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-8087
Practice Address - Country:US
Practice Address - Phone:931-645-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0107051558335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier