Provider Demographics
NPI:1841802048
Name:DAVIS, LATASSA (LMT)
Entity Type:Individual
Prefix:
First Name:LATASSA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 350068
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-0068
Mailing Address - Country:US
Mailing Address - Phone:407-256-2707
Mailing Address - Fax:
Practice Address - Street 1:2 CLAYMONT CT S
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8346
Practice Address - Country:US
Practice Address - Phone:407-256-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007924225700000X
FLMA25971225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist