Provider Demographics
NPI:1831156298
Name:MCINTOSH, LATANGRA M (APRN)
Entity type:Individual
Prefix:
First Name:LATANGRA
Middle Name:M
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-272-2244
Practice Address - Fax:813-272-3766
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9539101YM0800X
FLAPRN9330286363LF0000X, 363LP0808X
NH089900-23363LP0808X
FL3355632364SP0812X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765480400Medicaid