Provider Demographics
NPI:1457761413
Name:MILES, LATISHA
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:MILES
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 1:9299 CHIPPEWA TRL
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-9696
Mailing Address - Country:US
Mailing Address - Phone:707-245-6546
Mailing Address - Fax:
Practice Address - Street 1:9299 CHIPPEWA TRL
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-9696
Practice Address - Country:US
Practice Address - Phone:707-245-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003947A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant