Provider Demographics
NPI:1235638669
Name:ENNIS, LATARSHA
Entity Type:Individual
Prefix:
First Name:LATARSHA
Middle Name:
Last Name:ENNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 TWIN OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-6946
Mailing Address - Country:US
Mailing Address - Phone:702-472-3039
Mailing Address - Fax:
Practice Address - Street 1:2860 E FLAMINGO RD STE C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5270
Practice Address - Country:US
Practice Address - Phone:702-562-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3747P1801X, 372600000X, 372500000X, 3747A0650X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376J00000XNursing Service Related ProvidersHomemaker