Provider Demographics
NPI:1992187926
Name:ROSSER, LATOYA LAVELLE
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:LAVELLE
Last Name:ROSSER
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 1:5135 CARBONDALE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-4522
Mailing Address - Country:US
Mailing Address - Phone:614-375-0133
Mailing Address - Fax:
Practice Address - Street 1:5135 CARBONDALE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4522
Practice Address - Country:US
Practice Address - Phone:614-375-0133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2573337251E00000X
OH0339942251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0339942Medicaid
OH2573337Medicaid