Provider Demographics
NPI:1366864811
Name:ALLEN, LATRICIA ROCHELLE (CSFA)
Entity Type:Individual
Prefix:
First Name:LATRICIA
Middle Name:ROCHELLE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:ROCHELLE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CSFA
Mailing Address - Street 1:741 BEAUS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-4347
Mailing Address - Country:US
Mailing Address - Phone:228-297-6640
Mailing Address - Fax:
Practice Address - Street 1:741 BEAUS LANDING DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-4347
Practice Address - Country:US
Practice Address - Phone:228-297-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant