Provider Demographics
NPI:1760183180
Name:BURRIS, LATIA DONYELLE
Entity Type:Individual
Prefix:
First Name:LATIA
Middle Name:DONYELLE
Last Name:BURRIS
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 1:2415 PENNY RD STE 202
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-8123
Mailing Address - Country:US
Mailing Address - Phone:336-949-7525
Mailing Address - Fax:
Practice Address - Street 1:2415 PENNY RD STE 202
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8123
Practice Address - Country:US
Practice Address - Phone:336-949-7525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18824225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist