Provider Demographics
NPI:1134811086
Name:FALLA, SHANIQUE C (LDO)
Entity type:Individual
Prefix:
First Name:SHANIQUE
Middle Name:C
Last Name:FALLA
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3002
Mailing Address - Country:US
Mailing Address - Phone:954-331-3616
Mailing Address - Fax:954-473-5122
Practice Address - Street 1:4301 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3002
Practice Address - Country:US
Practice Address - Phone:954-331-3616
Practice Address - Fax:954-473-5122
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO7450156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician