Healthcare Provider Details

I. General information

NPI: 1144791591
Provider Name (Legal Business Name): LATISHICA EADEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2618 MERGANSER CT
HUMBLE TX
77396-4148
US

IV. Provider business mailing address

2618 MERGANSER CT
HUMBLE TX
77396-4148
US

V. Phone/Fax

Practice location:
  • Phone: 346-719-3814
  • Fax:
Mailing address:
  • Phone: 346-719-3814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number006355
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: