Basic Information
| Provider Information | |||||||||
| NPI: | 1497257125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAVENS | ||||||||
| FirstName: | LATISHA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2715 COLONIAL DR STE 100B | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038984802 | ||||||||
| FaxNumber: | 8038984007 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 HAMPTON ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292041002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038980123 | ||||||||
| FaxNumber: | 8038980154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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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 | 46442 | SC | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.