Provider Demographics
NPI:1265216931
Name:STEVENSON, LATASHA R
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:R
Last Name:STEVENSON
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 1:6465 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-2923
Mailing Address - Country:US
Mailing Address - Phone:317-654-4383
Mailing Address - Fax:
Practice Address - Street 1:6465 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-2923
Practice Address - Country:US
Practice Address - Phone:317-654-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1550237218344600000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1942960059Medicaid