Provider Demographics
NPI:1891452843
Name:JOHNSON, LATAURIS
Entity Type:Individual
Prefix:
First Name:LATAURIS
Middle Name:
Last Name:JOHNSON
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 1:89 NATE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:39092-3502
Mailing Address - Country:US
Mailing Address - Phone:601-717-3244
Mailing Address - Fax:601-510-9134
Practice Address - Street 1:405 BRIARWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3052
Practice Address - Country:US
Practice Address - Phone:601-345-1780
Practice Address - Fax:601-510-9134
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion