Provider Demographics
NPI:1992336192
Name:HEPBURN, ANTAKEISHA LAVONTE (MASTER WIG ARTIST)
Entity type:Individual
Prefix:
First Name:ANTAKEISHA
Middle Name:LAVONTE
Last Name:HEPBURN
Suffix:
Gender:F
Credentials:MASTER WIG ARTIST
Other - Prefix:
Other - First Name:ANTAKEISHA
Other - Middle Name:LAVONTE
Other - Last Name:HEPBURN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MASTER WIG ARTIST
Mailing Address - Street 1:2326 NW 51ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-3677
Mailing Address - Country:US
Mailing Address - Phone:786-291-7808
Mailing Address - Fax:
Practice Address - Street 1:2326 NW 51ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-3677
Practice Address - Country:US
Practice Address - Phone:786-291-7808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist