Provider Demographics
NPI:1538692991
Name:HENDERSON, LATASHA (MD)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:311 VETERANS BLVD STE B
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4726
Practice Address - Country:US
Practice Address - Phone:225-665-4554
Practice Address - Fax:225-665-6995
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA322455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program