Basic Information
| Provider Information | |||||||||
| NPI: | 1710370689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIALS | ||||||||
| FirstName: | LATASHA | ||||||||
| MiddleName: | TILLMAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 BILLINGSLEY RD | ||||||||
| Address2: | STE B | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282111009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044442400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2015 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5007494 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 5007494 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.