Provider Demographics
NPI:1144051962
Name:ESTRIDGE, LATISE SHEVONNE
Entity type:Individual
Prefix:
First Name:LATISE
Middle Name:SHEVONNE
Last Name:ESTRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 WESLEYAN RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3945
Mailing Address - Country:US
Mailing Address - Phone:937-581-5279
Mailing Address - Fax:
Practice Address - Street 1:7271 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2567
Practice Address - Country:US
Practice Address - Phone:937-203-4928
Practice Address - Fax:937-630-4618
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty