Provider Demographics
NPI:1821557265
Name:JAMES, LATIESHA COLISE
Entity Type:Individual
Prefix:
First Name:LATIESHA
Middle Name:COLISE
Last Name:JAMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATIESHA
Other - Middle Name:COLISE
Other - Last Name:BUTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-0683
Mailing Address - Country:US
Mailing Address - Phone:678-531-3452
Mailing Address - Fax:
Practice Address - Street 1:2529 TERRACE TRL
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3514
Practice Address - Country:US
Practice Address - Phone:334-947-7488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
GA171W00000X171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor