Provider Demographics
NPI:1497523013
Name:TILL, LATOREYA DENISE
Entity Type:Individual
Prefix:
First Name:LATOREYA
Middle Name:DENISE
Last Name:TILL
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 1:16935 EDLOYTOM WAY APT 346
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16935 EDLOYTOM WAY APT 346
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5459
Practice Address - Country:US
Practice Address - Phone:313-819-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230010426730205376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide