Provider Demographics
NPI:1316775620
Name:MOSLEY, LATOYIA SHANAE
Entity type:Individual
Prefix:
First Name:LATOYIA
Middle Name:SHANAE
Last Name:MOSLEY
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 1:5343 BELLEVILLE CROSSING ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-3108
Mailing Address - Country:US
Mailing Address - Phone:618-977-8242
Mailing Address - Fax:
Practice Address - Street 1:5343 BELLEVILLE CROSSING ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-3108
Practice Address - Country:US
Practice Address - Phone:618-977-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILM24053783911172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver