Provider Demographics
NPI:1720505019
Name:DUNFORD, LATASHA ANN-PEGRAM (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:ANN-PEGRAM
Last Name:DUNFORD
Suffix:
Gender:F
Credentials:AGACNP-BC
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 RAY C HUNT DR FL 3
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2981
Practice Address - Country:US
Practice Address - Phone:434-924-2224
Practice Address - Fax:434-982-3652
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175048208800000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No208800000XAllopathic & Osteopathic PhysiciansUrology