Healthcare Provider Details

I. General information

NPI: 1376240440
Provider Name (Legal Business Name): LATOSHA ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 DIANNE ST
SHREVEPORT LA
71119-5217
US

IV. Provider business mailing address

6525 DIANNE ST
SHREVEPORT LA
71119-5217
US

V. Phone/Fax

Practice location:
  • Phone: 318-814-9434
  • Fax:
Mailing address:
  • Phone: 318-814-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number485999
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number007898182
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: