Provider Demographics
NPI:1245984574
Name:RAYMOND, LATASHIA NICOLE
Entity type:Individual
Prefix:
First Name:LATASHIA
Middle Name:NICOLE
Last Name:RAYMOND
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 1:19 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3623
Mailing Address - Country:US
Mailing Address - Phone:919-520-7490
Mailing Address - Fax:
Practice Address - Street 1:632 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-3213
Practice Address - Country:US
Practice Address - Phone:919-520-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-06
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program