Provider Demographics
NPI:1659867778
Name:WHITE, LATISHA
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:WHITE
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 1:765 PIERCE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-2425
Mailing Address - Country:US
Mailing Address - Phone:614-223-1650
Mailing Address - Fax:
Practice Address - Street 1:765 PIERCE DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223
Practice Address - Country:US
Practice Address - Phone:614-223-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH154419164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty