Provider Demographics
NPI:1891416400
Name:LUCAS, LATOYA MICHELLE (CNA)
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:MICHELLE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 KINGSTON DR
Mailing Address - Street 2:
Mailing Address - City:MC BEE
Mailing Address - State:SC
Mailing Address - Zip Code:29101-9568
Mailing Address - Country:US
Mailing Address - Phone:843-861-5197
Mailing Address - Fax:
Practice Address - Street 1:432 KINGSTON DR
Practice Address - Street 2:
Practice Address - City:MC BEE
Practice Address - State:SC
Practice Address - Zip Code:29101-9568
Practice Address - Country:US
Practice Address - Phone:843-861-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC129296376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8433197330Medicaid