Provider Demographics
NPI:1861423782
Name:LAQUINDANUM, FATIMA L (PT)
Entity type:Individual
Prefix:MRS
First Name:FATIMA
Middle Name:L
Last Name:LAQUINDANUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 STAGE VILLAGE CV STE 1
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-4616
Mailing Address - Country:US
Mailing Address - Phone:901-828-1816
Mailing Address - Fax:901-737-9097
Practice Address - Street 1:2855 STAGE VILLAGE CV STE 1
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4616
Practice Address - Country:US
Practice Address - Phone:901-828-1816
Practice Address - Fax:901-737-9097
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPT 103140225100000X
TNPT 5144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3645364Medicare ID - Type UnspecifiedIND MEDICARE NUMBER