Provider Demographics
NPI:1801033436
Name:MOORE, LATANYA YVETTE
Entity Type:Individual
Prefix:MRS
First Name:LATANYA
Middle Name:YVETTE
Last Name:MOORE
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 1:3392 SW 131ST PLACE RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34473-7939
Mailing Address - Country:US
Mailing Address - Phone:352-812-7756
Mailing Address - Fax:
Practice Address - Street 1:3392 SW 131ST PLACE RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34473-7939
Practice Address - Country:US
Practice Address - Phone:352-812-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL687825396172V00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687825396Medicaid