Healthcare Provider Details

I. General information

NPI: 1538367859
Provider Name (Legal Business Name): MRS. LATASHA A THOMAS-FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2007
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 GUILFORD CT
SPRING LAKE NC
28390-7058
US

IV. Provider business mailing address

79 GUILFORD CT
SPRING LAKE NC
28390-7058
US

V. Phone/Fax

Practice location:
  • Phone: 910-497-0002
  • Fax:
Mailing address:
  • Phone: 910-497-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3408062
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: