Provider Demographics
NPI:1528311610
Name:BRISTOW, LATORA (LPN)
Entity type:Individual
Prefix:
First Name:LATORA
Middle Name:
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 KENRIDGE RD
Mailing Address - Street 2:4
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3442
Mailing Address - Country:US
Mailing Address - Phone:330-701-7115
Mailing Address - Fax:
Practice Address - Street 1:206 KENRIDGE RD
Practice Address - Street 2:4
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3442
Practice Address - Country:US
Practice Address - Phone:330-702-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRQ073259164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse