Provider Demographics
NPI:1770165144
Name:MONFORD, LATANYA
Entity type:Individual
Prefix:
First Name:LATANYA
Middle Name:
Last Name:MONFORD
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 1:2501 14TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-1935
Mailing Address - Country:US
Mailing Address - Phone:330-605-1183
Mailing Address - Fax:
Practice Address - Street 1:2501 14TH ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-1935
Practice Address - Country:US
Practice Address - Phone:330-605-1183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH324867510208376K00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant