Provider Demographics
NPI:1093376998
Name:SPIVEY, LATRICE R
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:R
Last Name:SPIVEY
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 1:9444 MCLEMORE CV
Mailing Address - Street 2:
Mailing Address - City:WALLS
Mailing Address - State:MS
Mailing Address - Zip Code:38680-9782
Mailing Address - Country:US
Mailing Address - Phone:901-383-0773
Mailing Address - Fax:
Practice Address - Street 1:9444 MCLEMORE CV
Practice Address - Street 2:
Practice Address - City:WALLS
Practice Address - State:MS
Practice Address - Zip Code:38680-9782
Practice Address - Country:US
Practice Address - Phone:901-383-0773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN88246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant