Provider Demographics
NPI:1427368570
Name:WHITTAKER, LACONNA MARYE (LPN)
Entity type:Individual
Prefix:
First Name:LACONNA
Middle Name:MARYE
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 CARL MILLER DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4408
Mailing Address - Country:US
Mailing Address - Phone:615-750-3880
Mailing Address - Fax:
Practice Address - Street 1:750 OLD HICKORY BLVD BLDG 1
Practice Address - Street 2:SUITE 190
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4528
Practice Address - Country:US
Practice Address - Phone:615-661-7594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000052463164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse