Provider Demographics
NPI:1013431220
Name:DUBOSE, LATASHA
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:DUBOSE
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 1:8491 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2412
Mailing Address - Country:US
Mailing Address - Phone:678-695-3734
Mailing Address - Fax:
Practice Address - Street 1:2930 BLUFF WINDS PL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8683
Practice Address - Country:US
Practice Address - Phone:678-695-3734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-29
Last Update Date:2017-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN094202164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse