Healthcare Provider Details

I. General information

NPI: 1144051962
Provider Name (Legal Business Name): LATISE SHEVONNE ESTRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

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

7271 N MAIN ST
DAYTON OH
45415-2567
US

IV. Provider business mailing address

1828 WESLEYAN RD
DAYTON OH
45406-3945
US

V. Phone/Fax

Practice location:
  • Phone: 937-203-4928
  • Fax: 937-630-4618
Mailing address:
  • Phone: 937-581-5279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: