Provider Demographics
NPI:1467103044
Name:SPRY, LATASHA (PRSS)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:SPRY
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 JEFFERSON RD STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-8815
Mailing Address - Country:US
Mailing Address - Phone:187-733-8272
Mailing Address - Fax:
Practice Address - Street 1:1109 JEFFERSON RD STE C
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8815
Practice Address - Country:US
Practice Address - Phone:877-338-2725
Practice Address - Fax:304-715-3537
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356980916OtherMEDICAID NPI
WV1356980916Medicaid