Provider Demographics
NPI:1689258956
Name:KING, LATOSHA BRINKLEY (RN)
Entity Type:Individual
Prefix:MRS
First Name:LATOSHA
Middle Name:BRINKLEY
Last Name:KING
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:LATOSHA
Other - Middle Name:BRINKLEY
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 562
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0562
Mailing Address - Country:US
Mailing Address - Phone:601-597-5076
Mailing Address - Fax:
Practice Address - Street 1:1581 HARRISTON RD
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-5439
Practice Address - Country:US
Practice Address - Phone:601-597-5076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902693163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse