Provider Demographics
NPI:1760971923
Name:THOMAS, LATRENA M
Entity Type:Individual
Prefix:
First Name:LATRENA
Middle Name:M
Last Name:THOMAS
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:PO BOX 77581
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-7581
Mailing Address - Country:US
Mailing Address - Phone:804-502-5840
Mailing Address - Fax:904-485-8541
Practice Address - Street 1:14091 SUMMER BREEZE DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-8913
Practice Address - Country:US
Practice Address - Phone:804-502-5840
Practice Address - Fax:904-485-8541
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15IV043320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019341700Medicaid