Healthcare Provider Details

I. General information

NPI: 1265918650
Provider Name (Legal Business Name): CHANCELINE Y LATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 12TH ST SE STE G35
WASHINGTON DC
20003-3738
US

IV. Provider business mailing address

4516 FORT TOTTEN DR NE # 17
WASHINGTON DC
20011-7523
US

V. Phone/Fax

Practice location:
  • Phone: 202-544-8090
  • Fax: 202-544-8091
Mailing address:
  • Phone: 202-550-8322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA13798
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: