Provider Demographics
NPI:1013407840
Name:SOLOMON, LATAVA
Entity Type:Individual
Prefix:
First Name:LATAVA
Middle Name:
Last Name:SOLOMON
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 1:20355 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1272
Mailing Address - Country:US
Mailing Address - Phone:313-742-8842
Mailing Address - Fax:
Practice Address - Street 1:20355 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1272
Practice Address - Country:US
Practice Address - Phone:313-742-8842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703119529164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse