Provider Demographics
NPI:1326775842
Name:WATTERS, LATASHA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:MARIE
Last Name:WATTERS
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 1:4 E B ST
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1214
Mailing Address - Country:US
Mailing Address - Phone:740-418-0804
Mailing Address - Fax:
Practice Address - Street 1:4 E B ST
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-1214
Practice Address - Country:US
Practice Address - Phone:740-418-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.180214.MEDS.IV164W00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181588Medicaid