Provider Demographics
NPI:1801567763
Name:COLTRANE, LATHAY
Entity type:Individual
Prefix:MS
First Name:LATHAY
Middle Name:
Last Name:COLTRANE
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:PO BOX 79113
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27417-9113
Mailing Address - Country:US
Mailing Address - Phone:336-669-2819
Mailing Address - Fax:336-299-9758
Practice Address - Street 1:3811 REPON ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-5536
Practice Address - Country:US
Practice Address - Phone:336-669-2819
Practice Address - Fax:336-299-9758
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1366594715Medicaid