Basic Information
| Provider Information | |||||||||
| NPI: | 1720276991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIDDLE | ||||||||
| FirstName: | LATISHA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654465317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1345 UNITY PL STE 235 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654465065 | ||||||||
| FaxNumber: | 7654465317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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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 | 246ZS0410X | 105640 | IN | Y |
No ID Information.