Healthcare Provider Details

I. General information

NPI: 1336980556
Provider Name (Legal Business Name): LATOSHA SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4319 PHILADELPHIA DR
DAYTON OH
45405-1928
US

IV. Provider business mailing address

4319 PHILADELPHIA DR
DAYTON OH
45405-1928
US

V. Phone/Fax

Practice location:
  • Phone: 190-164-4881
  • Fax:
Mailing address:
  • Phone: 901-644-8814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number5718684
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number5718684
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number5718684
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberRS533003
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number5718684
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: