Healthcare Provider Details

I. General information

NPI: 1720894918
Provider Name (Legal Business Name): CONYA LATISH LOFTON RCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 BLUE OAK DR
LAKEPORT CA
95453-6587
US

IV. Provider business mailing address

706 BLUE OAK DR
LAKEPORT CA
95453-6587
US

V. Phone/Fax

Practice location:
  • Phone: 323-302-6997
  • Fax:
Mailing address:
  • Phone: 323-302-6997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number15960
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: