Provider Demographics
NPI:1912591744
Name:LUCAS, LATYSHA
Entity type:Individual
Prefix:
First Name:LATYSHA
Middle Name:
Last Name:LUCAS
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 1:8714 GLENLOCH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-2115
Mailing Address - Country:US
Mailing Address - Phone:267-353-5092
Mailing Address - Fax:
Practice Address - Street 1:244 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-1777
Practice Address - Country:US
Practice Address - Phone:215-725-2496
Practice Address - Fax:215-725-3241
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker