Basic Information
| Provider Information | |||||||||
| NPI: | 1598411258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | LATOSHA | ||||||||
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| Credential: | CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 JENNINGS MILL RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | WATKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306777241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066135880 | ||||||||
| FaxNumber: | 7066135889 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 JENNINGS MILL RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | WATKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306777241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066135880 | ||||||||
| FaxNumber: | 7066135889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2022 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | GA | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.