Provider Demographics
NPI:1104554377
Name:ANDERSON, AQUILLA LAPORSHA
Entity type:Individual
Prefix:
First Name:AQUILLA
Middle Name:LAPORSHA
Last Name:ANDERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LINWA BLVD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4486
Mailing Address - Country:US
Mailing Address - Phone:864-260-2220
Mailing Address - Fax:
Practice Address - Street 1:1 LINWA BLVD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4486
Practice Address - Country:US
Practice Address - Phone:864-260-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC233546163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid