Provider Demographics
NPI:1962291401
Name:SMITH, LAQUESHA LARENDA (RN)
Entity type:Individual
Prefix:
First Name:LAQUESHA
Middle Name:LARENDA
Last Name:SMITH
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BROWNLEE CIR
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1651
Mailing Address - Country:US
Mailing Address - Phone:229-325-5384
Mailing Address - Fax:
Practice Address - Street 1:165 BROWNLEE CIR
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1651
Practice Address - Country:US
Practice Address - Phone:229-325-5384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN207444372600000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No372600000XNursing Service Related ProvidersAdult Companion