Provider Demographics
NPI:1528637402
Name:WILLIAMS, LATARSHA NIKON
Entity type:Individual
Prefix:
First Name:LATARSHA
Middle Name:NIKON
Last Name:WILLIAMS
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 1:5119 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-1646
Mailing Address - Country:US
Mailing Address - Phone:904-802-8734
Mailing Address - Fax:
Practice Address - Street 1:5119 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-1646
Practice Address - Country:US
Practice Address - Phone:904-802-8734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL237632376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion