Provider Demographics
NPI:1497778690
Name:BAXTER, LATASHA NICOLE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:NICOLE
Last Name:BAXTER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:LATASHA
Other - Middle Name:NICOLE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSN
Mailing Address - Street 1:11312 BIG HORN CT
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1428
Mailing Address - Country:US
Mailing Address - Phone:716-310-5495
Mailing Address - Fax:
Practice Address - Street 1:2121 MEDICAL PARK DR
Practice Address - Street 2:SUITE 2
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-4054
Practice Address - Country:US
Practice Address - Phone:301-681-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR171236363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1497778690Medicaid
MD021319ZDE1Medicare PIN
MD1497778690Medicaid
MD021319ZDEZMedicare PIN