Provider Demographics
NPI:1568190643
Name:SOUTHWELL, LATOYA SIMONE
Entity Type:Individual
Prefix:MRS
First Name:LATOYA
Middle Name:SIMONE
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 NYACK PLZ
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-3847
Mailing Address - Country:US
Mailing Address - Phone:845-598-7101
Mailing Address - Fax:
Practice Address - Street 1:505 NYACK PLZ
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3847
Practice Address - Country:US
Practice Address - Phone:845-598-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405055996374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY405055996Medicaid