Healthcare Provider Details

I. General information

NPI: 1619708260
Provider Name (Legal Business Name): TRACEY JUDITH LATIA SENIOR STNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4104 ORCHARD DALE DR NW APT N
CANTON OH
44709-2095
US

IV. Provider business mailing address

4104 ORCHARD DALE DR NW APT N
CANTON OH
44709-2095
US

V. Phone/Fax

Practice location:
  • Phone: 716-510-4216
  • Fax:
Mailing address:
  • Phone: 716-510-4216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number602837170524
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: