Provider Demographics
NPI:1497291389
Name:EDWARDS, LATIERIA STILLETTE
Entity Type:Individual
Prefix:
First Name:LATIERIA
Middle Name:STILLETTE
Last Name:EDWARDS
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 1:606 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-3224
Mailing Address - Country:US
Mailing Address - Phone:318-286-7952
Mailing Address - Fax:
Practice Address - Street 1:606 MONROE ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-3224
Practice Address - Country:US
Practice Address - Phone:318-286-7952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008688552343900000X
LA008688523747A0650X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty