Provider Demographics
NPI:1295697704
Name:AUSTIN, TAWANA LATRICE
Entity type:Individual
Prefix:
First Name:TAWANA
Middle Name:LATRICE
Last Name:AUSTIN
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 1:37 E DELMAR AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5903
Mailing Address - Country:US
Mailing Address - Phone:314-706-2854
Mailing Address - Fax:314-228-0252
Practice Address - Street 1:37 E DELMAR AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5903
Practice Address - Country:US
Practice Address - Phone:314-706-2854
Practice Address - Fax:314-228-0252
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-02
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251E00000XAgenciesHome Health