Provider Demographics
NPI:1790309946
Name:WEAVER-SPAULDING, LATORIA CHAVELL
Entity Type:Individual
Prefix:MRS
First Name:LATORIA
Middle Name:CHAVELL
Last Name:WEAVER-SPAULDING
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LATORIA
Other - Middle Name:CHAVELL
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5440 CHAMPION CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-6812
Mailing Address - Country:US
Mailing Address - Phone:330-400-9269
Mailing Address - Fax:
Practice Address - Street 1:5440 CHAMPION CREEK BLVD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-6812
Practice Address - Country:US
Practice Address - Phone:330-400-9269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X, 253Z00000X, 3747P1801X, 376J00000X
7703999253Z00000X, 343900000X, 385HR2050X
OH7703999253Z00000X
OH24091833747P1801X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH770399Medicaid
OH7715155Medicaid