Provider Demographics
NPI:1417658279
Name:LATIMORE, TINA MARIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:LATIMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:ISHMAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:512 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-5336
Mailing Address - Country:US
Mailing Address - Phone:984-345-3455
Mailing Address - Fax:984-840-5900
Practice Address - Street 1:512 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-5336
Practice Address - Country:US
Practice Address - Phone:984-345-3455
Practice Address - Fax:984-840-5900
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide