Provider Demographics
NPI:1144997800
Name:WADDELL, LA'TONYA
Entity type:Individual
Prefix:
First Name:LA'TONYA
Middle Name:
Last Name:WADDELL
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 1:12808 N POINT LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2342
Mailing Address - Country:US
Mailing Address - Phone:202-276-1510
Mailing Address - Fax:
Practice Address - Street 1:12808 N POINT LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-2342
Practice Address - Country:US
Practice Address - Phone:202-276-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist