Provider Demographics
NPI:1447790951
Name:PROVITT, LATASSIA
Entity Type:Individual
Prefix:
First Name:LATASSIA
Middle Name:
Last Name:PROVITT
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 1:115 RUE FELICITE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-5647
Mailing Address - Country:US
Mailing Address - Phone:337-326-6562
Mailing Address - Fax:
Practice Address - Street 1:115 RUE FELICITE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-5647
Practice Address - Country:US
Practice Address - Phone:337-326-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X, 374U00000X
LA3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide