Provider Demographics
NPI:1144051525
Name:MAZE, LAQUETA R
Entity type:Individual
Prefix:
First Name:LAQUETA
Middle Name:R
Last Name:MAZE
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 1:1209 OAKHILL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5636
Mailing Address - Country:US
Mailing Address - Phone:937-212-3529
Mailing Address - Fax:
Practice Address - Street 1:1209 OAKHILL AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5636
Practice Address - Country:US
Practice Address - Phone:937-212-3529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS005305175T00000X
APS005305175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist