Provider Demographics
NPI:1508479072
Name:JOHNSON, LATARSHA NICOLE (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:MS
First Name:LATARSHA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 BONMARK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234-2435
Mailing Address - Country:US
Mailing Address - Phone:804-319-5409
Mailing Address - Fax:
Practice Address - Street 1:10084 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4800
Practice Address - Country:US
Practice Address - Phone:804-319-5409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management