Provider Demographics
NPI:1902488778
Name:FAIR, LATRESIA (RN)
Entity Type:Individual
Prefix:
First Name:LATRESIA
Middle Name:
Last Name:FAIR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 LINDSEY WAY
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-4103
Mailing Address - Country:US
Mailing Address - Phone:786-351-9340
Mailing Address - Fax:
Practice Address - Street 1:1303 PARKER RD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5984
Practice Address - Country:US
Practice Address - Phone:786-351-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA262012163WC1500X, 163WH0200X, 163WI0500X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA863208181OtherINSURANCE COMPANIES
GA863208181Medicaid