Provider Demographics
NPI:1184911349
Name:FREEMAN-ROSS, LATAYATACHA O (FNP)
Entity type:Individual
Prefix:MS
First Name:LATAYATACHA
Middle Name:O
Last Name:FREEMAN-ROSS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:900 JOHNSON STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282
Mailing Address - Country:US
Mailing Address - Phone:318-574-5080
Mailing Address - Fax:318-574-5052
Practice Address - Street 1:900 JOHNSON STREET
Practice Address - Street 2:SUITE A
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282
Practice Address - Country:US
Practice Address - Phone:318-574-5080
Practice Address - Fax:318-574-5052
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA009726-7269363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA233598Medicaid