Provider Demographics
NPI:1245087733
Name:WOODBERRY, LATISEA
Entity type:Individual
Prefix:
First Name:LATISEA
Middle Name:
Last Name:WOODBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6989
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-6989
Mailing Address - Country:US
Mailing Address - Phone:903-293-4755
Mailing Address - Fax:
Practice Address - Street 1:2211 N ROBISON RD UNIT 6989
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75505-5779
Practice Address - Country:US
Practice Address - Phone:903-293-4755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)