Provider Demographics
NPI:1932735701
Name:WALTON, LAQUIANA
Entity Type:Individual
Prefix:
First Name:LAQUIANA
Middle Name:
Last Name:WALTON
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 1:1097 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-1609
Mailing Address - Country:US
Mailing Address - Phone:614-397-8843
Mailing Address - Fax:
Practice Address - Street 1:1097 FOREST ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-1609
Practice Address - Country:US
Practice Address - Phone:614-397-8843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0073614Medicaid