Provider Demographics
NPI:1184381659
Name:JETER, LATIFAH QUANAH (FNP-C)
Entity type:Individual
Prefix:
First Name:LATIFAH
Middle Name:QUANAH
Last Name:JETER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12832 SANDPINES LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-0403
Mailing Address - Country:US
Mailing Address - Phone:704-930-3145
Mailing Address - Fax:
Practice Address - Street 1:12832 SANDPINES LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-0403
Practice Address - Country:US
Practice Address - Phone:704-930-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCJETE-I10SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine