Provider Demographics
NPI:1326681198
Name:BURGESS, LATASHA R
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:R
Last Name:BURGESS
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 1:13720 OLD ST AUGUSTINE RD STE 8-236
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-7414
Mailing Address - Country:US
Mailing Address - Phone:866-974-6632
Mailing Address - Fax:866-974-6632
Practice Address - Street 1:13720 OLD SAINT AUGUSTINE RD STE 8-236
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7414
Practice Address - Country:US
Practice Address - Phone:866-974-6632
Practice Address - Fax:866-974-6632
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health