Provider Demographics
NPI:1609668540
Name:LAIRD, LATOSHA (AGNP-C)
Entity type:Individual
Prefix:
First Name:LATOSHA
Middle Name:
Last Name:LAIRD
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 720014
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-0014
Mailing Address - Country:US
Mailing Address - Phone:601-863-0258
Mailing Address - Fax:601-990-4288
Practice Address - Street 1:1450 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-9301
Practice Address - Country:US
Practice Address - Phone:601-863-0258
Practice Address - Fax:601-990-4288
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907449363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology