Basic Information
| Provider Information | |||||||||
| NPI: | 1477831113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LATISHA | ||||||||
| MiddleName: | SHUNTISE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299314425 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299314425 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2011 | ||||||||
| LastUpdateDate: | 07/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN062309 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.