Provider Demographics
NPI:1316326937
Name:GOOCH, LATISHA (LPN)
Entity type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:
Last Name:GOOCH
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 1:4042 MAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1633
Mailing Address - Country:US
Mailing Address - Phone:937-607-1779
Mailing Address - Fax:
Practice Address - Street 1:4042 MAYVIEW DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45416-1633
Practice Address - Country:US
Practice Address - Phone:937-607-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH159277164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse