Provider Demographics
NPI:1104602358
Name:BURGESS, LATOYIA WOODSON
Entity type:Individual
Prefix:
First Name:LATOYIA
Middle Name:WOODSON
Last Name:BURGESS
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 1:650 WHISPERWOOD PKWY
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-7868
Mailing Address - Country:US
Mailing Address - Phone:567-686-9272
Mailing Address - Fax:
Practice Address - Street 1:650 WHISPERWOOD PKWY
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-7868
Practice Address - Country:US
Practice Address - Phone:567-686-9272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376J00000X, 253Z00000X, 376K00000X, 385H00000X, 343800000X, 343900000X, 172A00000X, 174200000X, 251J00000X, 261QA0600X
OHLPN.155018.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No343800000XTransportation ServicesSecured Medical Transport (VAN)Group - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
No174200000XOther Service ProvidersMeals
No251J00000XAgenciesNursing Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care