Provider Demographics
NPI:1235374901
Name:WESLEY, LATRICE KENYETTA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:LATRICE
Middle Name:KENYETTA
Last Name:WESLEY
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 1:906 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5454
Mailing Address - Country:US
Mailing Address - Phone:937-580-7188
Mailing Address - Fax:
Practice Address - Street 1:906 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5454
Practice Address - Country:US
Practice Address - Phone:937-580-7188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN118904164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse