Provider Demographics
NPI:1841713831
Name:PAULK, LADIA SHAQWUNTA
Entity type:Individual
Prefix:
First Name:LADIA
Middle Name:SHAQWUNTA
Last Name:PAULK
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 1:585 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-2625
Mailing Address - Country:US
Mailing Address - Phone:863-272-0906
Mailing Address - Fax:
Practice Address - Street 1:412 LONGFELLOW BLVD STE 2
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2404
Practice Address - Country:US
Practice Address - Phone:863-272-0906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL74105225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist