Provider Demographics
NPI:1790491066
Name:SMITH, LATOSHA LAVAE
Entity Type:Individual
Prefix:
First Name:LATOSHA
Middle Name:LAVAE
Last Name:SMITH
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 1:2547 ORLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-8327
Mailing Address - Country:US
Mailing Address - Phone:513-254-5971
Mailing Address - Fax:
Practice Address - Street 1:2547 ORLAND AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-8327
Practice Address - Country:US
Practice Address - Phone:513-254-5971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400309601203374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH400309601203Medicaid