Provider Demographics
NPI:1881945137
Name:HAIRSTON, CYREATHEA LA'TRICE
Entity type:Individual
Prefix:
First Name:CYREATHEA
Middle Name:LA'TRICE
Last Name:HAIRSTON
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 1:1357 SCOVILLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-5231
Mailing Address - Country:US
Mailing Address - Phone:330-412-6351
Mailing Address - Fax:
Practice Address - Street 1:1357 SCOVILLE AVE SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-5231
Practice Address - Country:US
Practice Address - Phone:330-412-6351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
401392410512376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide