Provider Demographics
NPI:1902629017
Name:HUDSON, LATAVIA
Entity type:Individual
Prefix:
First Name:LATAVIA
Middle Name:
Last Name:HUDSON
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 1:16643 KEDZIE AVE STE 104-400
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-5512
Mailing Address - Country:US
Mailing Address - Phone:630-349-8333
Mailing Address - Fax:
Practice Address - Street 1:16643 KEDZIE AVE STE 104-400
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:IL
Practice Address - Zip Code:60428-5512
Practice Address - Country:US
Practice Address - Phone:630-349-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246RP1900X, 246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy