Provider Demographics
NPI:1306496971
Name:PRINCE, LATASHIA
Entity type:Individual
Prefix:
First Name:LATASHIA
Middle Name:
Last Name:PRINCE
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 1:4930 PROMENADE DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8719
Mailing Address - Country:US
Mailing Address - Phone:313-459-4906
Mailing Address - Fax:
Practice Address - Street 1:4930 PROMENADE DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8719
Practice Address - Country:US
Practice Address - Phone:404-587-9162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty