Provider Demographics
NPI:1215491147
Name:LORNES, LATRONDA JAQUETTE
Entity type:Individual
Prefix:
First Name:LATRONDA
Middle Name:JAQUETTE
Last Name:LORNES
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 1:12388 SHADY DALE RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OK
Mailing Address - Zip Code:73448-7327
Mailing Address - Country:US
Mailing Address - Phone:580-504-4512
Mailing Address - Fax:
Practice Address - Street 1:12388 SHADY DALE RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OK
Practice Address - Zip Code:73448-7327
Practice Address - Country:US
Practice Address - Phone:580-504-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212021224Z00000X
OK814224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant