Provider Demographics
NPI:1306612627
Name:STOVALL, LASHANDRA
Entity type:Individual
Prefix:
First Name:LASHANDRA
Middle Name:
Last Name:STOVALL
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 1:6320 WINSTON TRCE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8623
Mailing Address - Country:US
Mailing Address - Phone:470-357-3247
Mailing Address - Fax:
Practice Address - Street 1:6320 WINSTON TRCE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-8623
Practice Address - Country:US
Practice Address - Phone:470-357-3247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA200999251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health