Provider Demographics
NPI:1053818039
Name:WALLACE-HARDIMAN, LATONYA (BA, MSA)
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:WALLACE-HARDIMAN
Suffix:
Gender:F
Credentials:BA, MSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 SAND BAR LN
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-8034
Mailing Address - Country:US
Mailing Address - Phone:313-715-7170
Mailing Address - Fax:313-636-2290
Practice Address - Street 1:5830 CONNER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3458
Practice Address - Country:US
Practice Address - Phone:313-924-1456
Practice Address - Fax:313-636-2290
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain