Provider Demographics
NPI:1124683362
Name:FORT, LATONYA
Entity type:Individual
Prefix:MS
First Name:LATONYA
Middle Name:
Last Name:FORT
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:PO BOX 7641
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-0641
Mailing Address - Country:US
Mailing Address - Phone:314-368-8995
Mailing Address - Fax:
Practice Address - Street 1:4952 BEACON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63120-2210
Practice Address - Country:US
Practice Address - Phone:314-368-8995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health