Provider Demographics
NPI:1902416548
Name:HENDERSON, LATISHA LASHAY
Entity Type:Individual
Prefix:MS
First Name:LATISHA
Middle Name:LASHAY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LATISHA
Other - Middle Name:LASHAY
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EXECUTIVE DIRECTORE
Mailing Address - Street 1:28250 US HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7014
Mailing Address - Country:US
Mailing Address - Phone:251-202-0550
Mailing Address - Fax:
Practice Address - Street 1:28250 US HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7014
Practice Address - Country:US
Practice Address - Phone:251-202-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker