Provider Demographics
NPI:1801879754
Name:MIMS, LATONYA S (CRNA)
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:S
Last Name:MIMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2427 LAKECREST DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-3003
Mailing Address - Country:US
Mailing Address - Phone:318-560-2312
Mailing Address - Fax:
Practice Address - Street 1:2427 LAKECREST DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-3003
Practice Address - Country:US
Practice Address - Phone:318-560-2312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN243434367500000X
TX668574367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110172339AMedicaid
LA1195901Medicaid
LA3A572C734Medicare PIN
TX8L12665Medicare PIN