Provider Demographics
NPI:1689183089
Name:WILLIAMS, LATOYAL TANEKA
Entity Type:Individual
Prefix:
First Name:LATOYAL
Middle Name:TANEKA
Last Name:WILLIAMS
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 1:2320 EDGEWOOD AVE W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-2453
Mailing Address - Country:US
Mailing Address - Phone:904-732-0122
Mailing Address - Fax:
Practice Address - Street 1:2320 EDGEWOOD AVE W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-2453
Practice Address - Country:US
Practice Address - Phone:904-732-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management