Provider Demographics
NPI:1134382732
Name:BARNWELL, KEONA LATOSHA
Entity type:Individual
Prefix:MS
First Name:KEONA
Middle Name:LATOSHA
Last Name:BARNWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEONA
Other - Middle Name:LATOSHA
Other - Last Name:SLATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9951 ATLANTIC BLVD
Mailing Address - Street 2:SUITE 319
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6584
Mailing Address - Country:US
Mailing Address - Phone:386-405-4155
Mailing Address - Fax:
Practice Address - Street 1:847 ORANGE AVE
Practice Address - Street 2:STE. B
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4769
Practice Address - Country:US
Practice Address - Phone:386-405-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000658800Medicaid