Provider Demographics
NPI:1023245362
Name:CARROLL, LATISHA JANINE (RN)
Entity type:Individual
Prefix:MS
First Name:LATISHA
Middle Name:JANINE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:1391 W 5TH AVE # 241
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2902
Mailing Address - Country:US
Mailing Address - Phone:614-935-4785
Mailing Address - Fax:614-413-3956
Practice Address - Street 1:655 N CASSADY AVE STE 7
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-2720
Practice Address - Country:US
Practice Address - Phone:614-843-4013
Practice Address - Fax:614-413-3956
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-13
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173320101YA0400X
OHRN357419163WC1600X, 163WH0200X, 163WM1400X, 163W00000X
174H00000X, 225700000X
OH33.025302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No174H00000XOther Service ProvidersHealth Educator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0117919Medicaid