Provider Demographics
NPI:1104350487
Name:HARLEY-HAMPTON, LAWANDA X
Entity type:Individual
Prefix:
First Name:LAWANDA
Middle Name:
Last Name:HARLEY-HAMPTON
Suffix:X
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 1:1320 N.W. SUMMERCREST BLVD.
Mailing Address - Street 2:APT. 211
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-9434
Mailing Address - Country:US
Mailing Address - Phone:708-305-0855
Mailing Address - Fax:
Practice Address - Street 1:1320 N.W. SUMMERCREST BLVD.
Practice Address - Street 2:APT. 211
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-9434
Practice Address - Country:US
Practice Address - Phone:708-305-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41169749172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver