Provider Demographics
NPI:1780863795
Name:FOX, LATRISHA R (LPN/RN)
Entity Type:Individual
Prefix:
First Name:LATRISHA
Middle Name:R
Last Name:FOX
Suffix:
Gender:F
Credentials:LPN/RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 RAVENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1545
Mailing Address - Country:US
Mailing Address - Phone:585-305-7338
Mailing Address - Fax:
Practice Address - Street 1:491 RAVENWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1545
Practice Address - Country:US
Practice Address - Phone:585-305-7338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5717831163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02042015Medicaid