Provider Demographics
NPI:1568239242
Name:ABBOTT EDISON, LATISHA MARIE
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:MARIE
Last Name:ABBOTT EDISON
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 1:4000 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3816
Mailing Address - Country:US
Mailing Address - Phone:757-920-8841
Mailing Address - Fax:
Practice Address - Street 1:4000 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3816
Practice Address - Country:US
Practice Address - Phone:757-920-8841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator