Provider Demographics
NPI:1578344370
Name:RENE, LATASHA (STUDENT)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:RENE
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:
Other - Last Name:FLOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STUDENT
Mailing Address - Street 1:1404 SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:AUBREY
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2728
Mailing Address - Country:US
Mailing Address - Phone:469-371-4335
Mailing Address - Fax:
Practice Address - Street 1:1404 SUMNER ST
Practice Address - Street 2:
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227-2728
Practice Address - Country:US
Practice Address - Phone:469-371-4335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX1270112405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program