Provider Demographics
NPI:1730660952
Name:RIDDICK, LATRESE L
Entity Type:Individual
Prefix:
First Name:LATRESE
Middle Name:L
Last Name:RIDDICK
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 1:418 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-5315
Mailing Address - Country:US
Mailing Address - Phone:757-214-4416
Mailing Address - Fax:758-809-1822
Practice Address - Street 1:418 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-214-4416
Practice Address - Fax:758-809-1822
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-25
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA203735-700786172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver