Provider Demographics
NPI:1871182642
Name:SULLIVAN, LATASHA G
Entity Type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:G
Last Name:SULLIVAN
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 1:9 HOGAN DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-5909
Mailing Address - Country:US
Mailing Address - Phone:864-209-5208
Mailing Address - Fax:
Practice Address - Street 1:9 HOGAN DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5909
Practice Address - Country:US
Practice Address - Phone:864-209-5208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies