Provider Demographics
NPI:1285183285
Name:JORDAN, LATASHA (LPN)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:JORDAN
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 1:40 MAPLE FIELDS DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2595
Mailing Address - Country:US
Mailing Address - Phone:845-798-4975
Mailing Address - Fax:
Practice Address - Street 1:40 MAPLE FIELDS DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2595
Practice Address - Country:US
Practice Address - Phone:845-798-4975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-02
Last Update Date:2016-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310520164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse