Provider Demographics
NPI:1679035265
Name:HARDAWAY, LATITIA
Entity Type:Individual
Prefix:
First Name:LATITIA
Middle Name:
Last Name:HARDAWAY
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 1:4673 E 173RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-3903
Mailing Address - Country:US
Mailing Address - Phone:216-370-8187
Mailing Address - Fax:
Practice Address - Street 1:4673 E 173RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-3903
Practice Address - Country:US
Practice Address - Phone:216-370-8187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor