Provider Demographics
NPI:1265393029
Name:SPIVEY, LATASHA
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:SPIVEY
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 1:6142 WATERLOO AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-8244
Mailing Address - Country:US
Mailing Address - Phone:321-302-3613
Mailing Address - Fax:321-302-3613
Practice Address - Street 1:1446 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4336
Practice Address - Country:US
Practice Address - Phone:321-291-3722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-20
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility