Provider Demographics
NPI:1255120986
Name:WASHINGTON, LATISHA ALEXANDRIA RENEE
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:ALEXANDRIA RENEE
Last Name:WASHINGTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9581 MOUNTAIN HOME DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5762
Mailing Address - Country:US
Mailing Address - Phone:910-261-1376
Mailing Address - Fax:
Practice Address - Street 1:150 FRANCAM DR STE 124
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-4500
Practice Address - Country:US
Practice Address - Phone:910-229-3924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20583225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty