Healthcare Provider Details

I. General information

NPI: 1902629017
Provider Name (Legal Business Name): LATAVIA HUDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16643 KEDZIE AVE STE 104-400
MARKHAM IL
60428-5512
US

IV. Provider business mailing address

16643 KEDZIE AVE STE 104-400
MARKHAM IL
60428-5512
US

V. Phone/Fax

Practice location:
  • Phone: 630-349-8333
  • Fax:
Mailing address:
  • Phone: 630-349-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: