Provider Demographics
NPI:1265918874
Name:MOSLEY, BERTISHIA LASHANTI (CNA)
Entity type:Individual
Prefix:MRS
First Name:BERTISHIA
Middle Name:LASHANTI
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 FULTON WAY
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-1517
Mailing Address - Country:US
Mailing Address - Phone:727-565-9029
Mailing Address - Fax:
Practice Address - Street 1:2308 FULTON WAY
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774
Practice Address - Country:US
Practice Address - Phone:727-565-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X, 261QM0855X, 261QD1600X
320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251E00000XAgenciesHome Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022971400Medicaid