Provider Demographics
NPI:1366086282
Name:BLUE, LATASHA
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:BLUE
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:PO BOX 31032
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-1032
Mailing Address - Country:US
Mailing Address - Phone:252-414-0999
Mailing Address - Fax:
Practice Address - Street 1:313 OLIVE BRANCH BLVD
Practice Address - Street 2:
Practice Address - City:GRIFTON
Practice Address - State:NC
Practice Address - Zip Code:28530-8584
Practice Address - Country:US
Practice Address - Phone:252-531-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25441176172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver