Provider Demographics
NPI:1306362926
Name:CARTER, LA TAVIA DOMONIQUE
Entity Type:Individual
Prefix:MS
First Name:LA TAVIA
Middle Name:DOMONIQUE
Last Name:CARTER
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 1:10700 FUQUA ST APT 190
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-2443
Mailing Address - Country:US
Mailing Address - Phone:281-786-9809
Mailing Address - Fax:346-229-4101
Practice Address - Street 1:10700 FUQUA ST APT 190
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-2443
Practice Address - Country:US
Practice Address - Phone:281-786-9809
Practice Address - Fax:346-229-4101
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX474753724Medicaid
TX474361671Medicaid