Provider Demographics
NPI:1417589649
Name:WEAVER, LATAUNJA PARESE
Entity Type:Individual
Prefix:
First Name:LATAUNJA
Middle Name:PARESE
Last Name:WEAVER
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 1:7436 S ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-2032
Mailing Address - Country:US
Mailing Address - Phone:773-503-9114
Mailing Address - Fax:
Practice Address - Street 1:7436 S ELLIS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-2032
Practice Address - Country:US
Practice Address - Phone:773-503-9114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043077883164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164W00000XMedicaid