Provider Demographics
NPI:1700331485
Name:BROOKS, LATIDA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:LATIDA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 TRAMMELL RD APT 83
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1350
Mailing Address - Country:US
Mailing Address - Phone:217-520-2835
Mailing Address - Fax:
Practice Address - Street 1:6001 TRAMMELL RD APT 83
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1350
Practice Address - Country:US
Practice Address - Phone:217-520-2835
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
GARN248436163W00000X
IL041422032163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse