Healthcare Provider Details

I. General information

NPI: 1609668540
Provider Name (Legal Business Name): LATOSHA LAIRD AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SOUTHPOINTE DR STE D
BYRAM MS
39272-5528
US

IV. Provider business mailing address

130 SOUTHPOINTE DR STE D
BYRAM MS
39272-5528
US

V. Phone/Fax

Practice location:
  • Phone: 601-863-0258
  • Fax: 601-990-4288
Mailing address:
  • Phone: 601-863-0258
  • Fax: 601-990-4288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number907449
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number907449
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: