Provider Demographics
NPI:1861852444
Name:KISTO, LATCHMI JASODRA (LPN)
Entity type:Individual
Prefix:MRS
First Name:LATCHMI
Middle Name:JASODRA
Last Name:KISTO
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 1:13007 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1515
Mailing Address - Country:US
Mailing Address - Phone:516-754-2244
Mailing Address - Fax:
Practice Address - Street 1:13007 97TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1515
Practice Address - Country:US
Practice Address - Phone:516-754-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324875164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse