Provider Demographics
NPI:1770767030
Name:WARREN, LETHA DEMETRA
Entity type:Individual
Prefix:MRS
First Name:LETHA
Middle Name:DEMETRA
Last Name:WARREN
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 1:306 S HIGH SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-3414
Mailing Address - Country:US
Mailing Address - Phone:601-736-4035
Mailing Address - Fax:601-736-4037
Practice Address - Street 1:306 S HIGH SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3414
Practice Address - Country:US
Practice Address - Phone:601-736-1448
Practice Address - Fax:601-736-6067
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS343900000X343900000X
MS376J00000X376J00000X
MS385H00000X385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02323791Medicaid
MS01631705Medicaid
MS03907701Medicaid