Provider Demographics
NPI:1124661228
Name:MURRAY, LATYRA S
Entity type:Individual
Prefix:
First Name:LATYRA
Middle Name:S
Last Name:MURRAY
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 1:20900 BOTSFORD DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5914
Mailing Address - Country:US
Mailing Address - Phone:313-627-0767
Mailing Address - Fax:
Practice Address - Street 1:24100 SOUTHFIELD RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2850
Practice Address - Country:US
Practice Address - Phone:313-627-0767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker