Provider Demographics
NPI:1811466360
Name:WALKER, LATASHA NICOLE
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:NICOLE
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1425 STARR AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-2456
Mailing Address - Country:US
Mailing Address - Phone:419-893-0631
Mailing Address - Fax:419-936-7606
Practice Address - Street 1:544 EAST WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-2706
Practice Address - Country:US
Practice Address - Phone:419-693-0631
Practice Address - Fax:419-936-7606
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0323374Medicaid