Provider Demographics
NPI:1790401602
Name:BROCKINGTON, LATASHA NYE
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:NYE
Last Name:BROCKINGTON
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 1:7000 S KENFIG DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3866
Mailing Address - Country:US
Mailing Address - Phone:843-834-4225
Mailing Address - Fax:
Practice Address - Street 1:7000 S KENFIG DR
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3866
Practice Address - Country:US
Practice Address - Phone:843-834-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374J00000X
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty