Provider Demographics
NPI:1235926718
Name:WILLIS, LATEISHA LYNN VANTRICE (CNA)
Entity type:Individual
Prefix:MRS
First Name:LATEISHA LYNN
Middle Name:VANTRICE
Last Name:WILLIS
Suffix:
Gender:
Credentials:CNA
Other - Prefix:
Other - First Name:LATEISHA LYNN
Other - Middle Name:VANTRICE
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:1839 N 39TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-3915
Mailing Address - Country:US
Mailing Address - Phone:817-819-7710
Mailing Address - Fax:
Practice Address - Street 1:1839 N 39TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-3915
Practice Address - Country:US
Practice Address - Phone:817-819-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ297178376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide