Provider Demographics
NPI:1659872141
Name:DAVIS, LATASHA
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:DAVIS
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 1:2122 BELLFLOWER WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-6740
Mailing Address - Country:US
Mailing Address - Phone:757-335-1867
Mailing Address - Fax:
Practice Address - Street 1:2122 BELLFLOWER WAY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-6740
Practice Address - Country:US
Practice Address - Phone:757-335-1867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT61777319343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)