Provider Demographics
NPI:1245011220
Name:DUBOIS, LATASHA NICOLE (MT)
Entity type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:NICOLE
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:NICOLE
Other - Last Name:KIRKLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MT
Mailing Address - Street 1:806 TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4508
Mailing Address - Country:US
Mailing Address - Phone:707-655-8910
Mailing Address - Fax:
Practice Address - Street 1:806 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4508
Practice Address - Country:US
Practice Address - Phone:707-655-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist