Provider Demographics
NPI:1457242232
Name:SMALLS, LATIKA R LESEANE
Entity type:Individual
Prefix:
First Name:LATIKA
Middle Name:R LESEANE
Last Name:SMALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATIKA
Other - Middle Name:RENE
Other - Last Name:LESEANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:10 FIORE DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-6225
Mailing Address - Country:US
Mailing Address - Phone:912-660-2140
Mailing Address - Fax:
Practice Address - Street 1:10 FIORE DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-6225
Practice Address - Country:US
Practice Address - Phone:912-660-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-10
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GARN207066390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty