Provider Demographics
NPI:1518304906
Name:LATTIMORE, LAVONE RENITA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LAVONE
Middle Name:RENITA
Last Name:LATTIMORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:LAVONE
Other - Middle Name:RENITA
Other - Last Name:JONES-LATTIMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:5702 CENTER DR
Mailing Address - Street 2:N/A
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2302
Mailing Address - Country:US
Mailing Address - Phone:301-906-7168
Mailing Address - Fax:301-420-3480
Practice Address - Street 1:5702 CENTER DR
Practice Address - Street 2:N/A
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2302
Practice Address - Country:US
Practice Address - Phone:301-906-7168
Practice Address - Fax:301-420-3480
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-27
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM02482174400000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist