Provider Demographics
NPI:1871850941
Name:BLACKWELL, LATISHA
Entity Type:Individual
Prefix:MS
First Name:LATISHA
Middle Name:
Last Name:BLACKWELL
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 1:58 HILL ST
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 HILL ST
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1537
Practice Address - Country:US
Practice Address - Phone:313-138-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3747P1801X, 3747A0650X
3747P1801X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant