Provider Demographics
NPI:1104518307
Name:NELLONS, LATASHA M (LPN)
Entity type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:M
Last Name:NELLONS
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 1:213 E ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-2503
Mailing Address - Country:US
Mailing Address - Phone:315-991-5391
Mailing Address - Fax:
Practice Address - Street 1:213 E ELLIS ST
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-2503
Practice Address - Country:US
Practice Address - Phone:315-991-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345249164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse