Provider Demographics
NPI:1336743483
Name:PHILLIPS, LATEASH TANIE (CNA)
Entity Type:Individual
Prefix:
First Name:LATEASH
Middle Name:TANIE
Last Name:PHILLIPS
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 1:10410 LAKEPOINTE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2408
Mailing Address - Country:US
Mailing Address - Phone:313-878-4349
Mailing Address - Fax:
Practice Address - Street 1:10410 LAKEPOINTE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2408
Practice Address - Country:US
Practice Address - Phone:313-878-4349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230012906461206376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide