Provider Demographics
NPI:1982352720
Name:ATANDA, LATIFAT
Entity Type:Individual
Prefix:
First Name:LATIFAT
Middle Name:
Last Name:ATANDA
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 1:3090 OUTLET PKWY APT 212
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7241
Mailing Address - Country:US
Mailing Address - Phone:469-279-9085
Mailing Address - Fax:
Practice Address - Street 1:3090 OUTLET PKWY APT 212
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7241
Practice Address - Country:US
Practice Address - Phone:469-279-9085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1345354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist