Provider Demographics
NPI:1497257125
Name:HAVENS, LATISHA J (LPN)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:J
Last Name:HAVENS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 COLONIAL DR STE 100B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6818
Mailing Address - Country:US
Mailing Address - Phone:803-898-4802
Mailing Address - Fax:803-898-4007
Practice Address - Street 1:2000 HAMPTON ST FL 3
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1002
Practice Address - Country:US
Practice Address - Phone:803-898-0123
Practice Address - Fax:803-898-0154
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC46442164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse