Provider Demographics
NPI:1407305311
Name:GRAY, LATASHA DANIELLE
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:DANIELLE
Last Name:GRAY
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 1:3027 W 13 MILE RD APT 339
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2971
Mailing Address - Country:US
Mailing Address - Phone:248-761-8355
Mailing Address - Fax:
Practice Address - Street 1:3027 W 13 MILE RD APT 339
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-2971
Practice Address - Country:US
Practice Address - Phone:248-761-8355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other