Provider Demographics
NPI:1174024350
Name:HUDSON, LATANIA (AE-C, RN)
Entity Type:Individual
Prefix:MR
First Name:LATANIA
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:AE-C, RN
Other - Prefix:
Other - First Name:LATINA
Other - Middle Name:BURKS
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HEALTHY HOMES CERT
Mailing Address - Street 1:2245 COTTONTAIL DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-1712
Mailing Address - Country:US
Mailing Address - Phone:314-497-6638
Mailing Address - Fax:
Practice Address - Street 1:2220 LEMP AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2700
Practice Address - Country:US
Practice Address - Phone:314-658-4893
Practice Address - Fax:314-898-4926
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006025679163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOXXXXXXXXXXMedicaid