Provider Demographics
NPI:1922755164
Name:STALLWORTH, LATASHA JENEE
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:JENEE
Last Name:STALLWORTH
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 1:11211 VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2727
Mailing Address - Country:US
Mailing Address - Phone:216-308-7195
Mailing Address - Fax:
Practice Address - Street 1:4992 DONOVAN DR
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2025
Practice Address - Country:US
Practice Address - Phone:216-924-8012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0122796Medicaid
OH1825645Medicaid