Provider Demographics
NPI:1376395418
Name:FULTON, LATANYA DENEEN (CERTIFIED DOULA)
Entity Type:Individual
Prefix:MRS
First Name:LATANYA
Middle Name:DENEEN
Last Name:FULTON
Suffix:
Gender:F
Credentials:CERTIFIED DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SAINT JOHN DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3329
Mailing Address - Country:US
Mailing Address - Phone:314-896-3868
Mailing Address - Fax:
Practice Address - Street 1:6400 W MAIN ST STE 3K
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3806
Practice Address - Country:US
Practice Address - Phone:314-896-3868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula