Provider Demographics
NPI:1235797051
Name:GIBBS, LATASHA PAULETTE
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:PAULETTE
Last Name:GIBBS
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 1:1530 MISTY VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7033
Mailing Address - Country:US
Mailing Address - Phone:770-539-5662
Mailing Address - Fax:
Practice Address - Street 1:4955 SUGARLOAF PKWY STE F
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6997
Practice Address - Country:US
Practice Address - Phone:800-324-2688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist