Provider Demographics
NPI:1639636855
Name:THOMAS, LATESA RENAE (CNA)
Entity Type:Individual
Prefix:
First Name:LATESA
Middle Name:RENAE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:LATESA
Other - Middle Name:RENAE
Other - Last Name:ENGRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11611 GRAYTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1643
Mailing Address - Country:US
Mailing Address - Phone:313-556-4769
Mailing Address - Fax:313-473-8192
Practice Address - Street 1:11611 GRAYTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1643
Practice Address - Country:US
Practice Address - Phone:313-556-4769
Practice Address - Fax:313-473-8192
Is Sole Proprietor?:No
Enumeration Date:2019-02-24
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230109450998372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion