Provider Demographics
NPI:1114286978
Name:LATASIEWICZ, ILENE S (RN)
Entity Type:Individual
Prefix:MRS
First Name:ILENE
Middle Name:S
Last Name:LATASIEWICZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4986 N ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-5017
Mailing Address - Country:US
Mailing Address - Phone:248-475-4701
Mailing Address - Fax:248-475-5777
Practice Address - Street 1:4986 N ADAMS RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48306-5017
Practice Address - Country:US
Practice Address - Phone:248-475-4701
Practice Address - Fax:248-475-5777
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704070667163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse