Provider Demographics
NPI:1376276253
Name:SMITH, LATOYA JEAN
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:JEAN
Last Name:SMITH
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 1:535 W STEWART ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-4050
Mailing Address - Country:US
Mailing Address - Phone:937-829-1178
Mailing Address - Fax:
Practice Address - Street 1:535 W STEWART ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4050
Practice Address - Country:US
Practice Address - Phone:937-829-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN746095172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver