Provider Demographics
NPI:1982995221
Name:BURRELL, LATEISHA LANORE
Entity Type:Individual
Prefix:
First Name:LATEISHA
Middle Name:LANORE
Last Name:BURRELL
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 1:22 QUAILBUSH DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-7964
Mailing Address - Country:US
Mailing Address - Phone:702-265-8155
Mailing Address - Fax:
Practice Address - Street 1:22 QUAILBUSH DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-7964
Practice Address - Country:US
Practice Address - Phone:702-265-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner