Healthcare Provider Details

I. General information

NPI: 1679449011
Provider Name (Legal Business Name): LATOYA JEANETTE HAIRSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2025
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DEER STAND DR
MADISON NC
27025-8095
US

IV. Provider business mailing address

200 DEER STAND DR
MADISON NC
27025-8095
US

V. Phone/Fax

Practice location:
  • Phone: 336-500-2114
  • Fax:
Mailing address:
  • Phone: 336-500-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number76683
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: