Provider Demographics
NPI:1962163105
Name:WADE, LATRESHA ROCHELLE (NP)
Entity type:Individual
Prefix:MRS
First Name:LATRESHA
Middle Name:ROCHELLE
Last Name:WADE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 W COMMERCIAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8040
Mailing Address - Country:US
Mailing Address - Phone:501-416-0117
Mailing Address - Fax:
Practice Address - Street 1:14 TREVINO CV
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-9107
Practice Address - Country:US
Practice Address - Phone:501-416-0117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-09
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR217904363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health