Healthcare Provider Details

I. General information

NPI: 1790377299
Provider Name (Legal Business Name): LATANYA MARVEL BEAMON CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LATANYA MARVEL BROWN CRT

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 W ALMY AVE
FRESNO CA
93706-5603
US

IV. Provider business mailing address

263 W ALMY AVE
FRESNO CA
93706-5603
US

V. Phone/Fax

Practice location:
  • Phone: 559-721-8746
  • Fax:
Mailing address:
  • Phone: 559-721-8746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRHM00078473
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License NumberRHM00078473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: