Provider Demographics
NPI:1629849112
Name:CLIFFORD, LATASHA
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:CLIFFORD
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 1:26 JACK ROUSH WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45144-1419
Mailing Address - Country:US
Mailing Address - Phone:937-301-1828
Mailing Address - Fax:
Practice Address - Street 1:26 JACK ROUSH WAY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45144-1419
Practice Address - Country:US
Practice Address - Phone:937-301-1828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant