Provider Demographics
NPI:1518761261
Name:CUNNINGHAM, LATEISHA SHAVONTE
Entity type:Individual
Prefix:
First Name:LATEISHA
Middle Name:SHAVONTE
Last Name:CUNNINGHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 OGLE ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-3626
Mailing Address - Country:US
Mailing Address - Phone:662-646-0183
Mailing Address - Fax:
Practice Address - Street 1:808 OGLE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-3626
Practice Address - Country:US
Practice Address - Phone:662-646-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS801063923172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver