Healthcare Provider Details

I. General information

NPI: 1316375124
Provider Name (Legal Business Name): LATRICE WADDELL CNS-PMH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2013
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 STARR AVE
TOLEDO OH
43605
US

IV. Provider business mailing address

1425 STARR AVE
TOLEDO OH
43605-2456
US

V. Phone/Fax

Practice location:
  • Phone: 419-693-0631
  • Fax: 419-936-7606
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAPRN.CNS.15185
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.344000
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number0024196812
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberCOA15185NS
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704413076
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704413076
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: