Provider Demographics
NPI:1225451792
Name:ANDERSON, LATRICE (RN)
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:
Last Name:ANDERSON
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 1:9303 STONESTREET RD
Mailing Address - Street 2:#204
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-2864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9303 STONESTREET RD
Practice Address - Street 2:#204
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-2864
Practice Address - Country:US
Practice Address - Phone:502-407-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5009225700000X
KY1098780163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist