Provider Demographics
NPI:1144812397
Name:KING, LATISHIA (LPN)
Entity type:Individual
Prefix:
First Name:LATISHIA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-2309
Mailing Address - Country:US
Mailing Address - Phone:706-975-9655
Mailing Address - Fax:
Practice Address - Street 1:139 HENRY PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6636
Practice Address - Country:US
Practice Address - Phone:770-358-5252
Practice Address - Fax:770-898-7412
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN092595164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2199LKOtherBCBS