Healthcare Provider Details

I. General information

NPI: 1679407209
Provider Name (Legal Business Name): LATISHA ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 N SPAULDING AVE APT 3W
CHICAGO IL
60625-5051
US

IV. Provider business mailing address

4910 N SPAULDING AVE APT 3W
CHICAGO IL
60625-5051
US

V. Phone/Fax

Practice location:
  • Phone: 724-496-9045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number100826
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: