Provider Demographics
NPI:1700575602
Name:WORMELY, LATISHA (CNS, LDN)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:WORMELY
Suffix:
Gender:F
Credentials:CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-9250
Mailing Address - Country:US
Mailing Address - Phone:623-512-9236
Mailing Address - Fax:
Practice Address - Street 1:400 S 4TH ST STE 500
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-6207
Practice Address - Country:US
Practice Address - Phone:702-708-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX6087133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist