Healthcare Provider Details

I. General information

NPI: 1700575602
Provider Name (Legal Business Name): LATISHA WORMELY CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 4TH ST STE 500
LAS VEGAS NV
89101-6207
US

IV. Provider business mailing address

200 QUAIL RUN
GOLDSBORO NC
27530-9250
US

V. Phone/Fax

Practice location:
  • Phone: 702-708-1686
  • Fax:
Mailing address:
  • Phone: 623-512-9236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX6087
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: