Provider Demographics
NPI:1477830180
Name:TEMPLE, LATASHA NICOLE (ATC)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:NICOLE
Last Name:TEMPLE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7304 CHADS CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-5702
Mailing Address - Country:US
Mailing Address - Phone:404-725-7850
Mailing Address - Fax:
Practice Address - Street 1:1975 HIGHWAY 54 W
Practice Address - Street 2:SUITE 210
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4794
Practice Address - Country:US
Practice Address - Phone:770-632-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0019842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer