Provider Demographics
NPI:1548401607
Name:MAXWELL, LATISHA A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:A
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LATISHA
Other - Middle Name:A
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:43 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-2834
Mailing Address - Country:US
Mailing Address - Phone:716-563-4486
Mailing Address - Fax:
Practice Address - Street 1:43 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-2834
Practice Address - Country:US
Practice Address - Phone:716-563-4486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280660164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse