Provider Demographics
NPI:1316491954
Name:ANDERSON, LATRICE
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:
Last Name:ANDERSON
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 1:22425 BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3819
Mailing Address - Country:US
Mailing Address - Phone:313-910-1821
Mailing Address - Fax:586-218-8228
Practice Address - Street 1:22425 BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3819
Practice Address - Country:US
Practice Address - Phone:313-910-1821
Practice Address - Fax:586-218-8228
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide