Healthcare Provider Details

I. General information

NPI: 1528806619
Provider Name (Legal Business Name): LATYA HURT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 DR MARY MCLEOD BETHUNE BLVD
DAYTONA BEACH FL
32114-3012
US

IV. Provider business mailing address

3103 STRATA CT
SUFFOLK VA
23434-7265
US

V. Phone/Fax

Practice location:
  • Phone: 386-481-2000
  • Fax:
Mailing address:
  • Phone: 757-943-2677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberT64731834
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: