Provider Demographics
NPI:1356896088
Name:RATLIFF, ANTONIETTE LATASHA
Entity type:Individual
Prefix:MRS
First Name:ANTONIETTE
Middle Name:LATASHA
Last Name:RATLIFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TASHA
Other - Middle Name:
Other - Last Name:RATLIFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6802
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33508-6013
Mailing Address - Country:US
Mailing Address - Phone:813-495-4276
Mailing Address - Fax:
Practice Address - Street 1:1315 E 7TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-3607
Practice Address - Country:US
Practice Address - Phone:813-495-4276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 14709101YM0800X
FLPN 5198859164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse