=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417658279
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA MARIE LATIMORE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2023
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 W THOMAS ST
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27804-5336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-345-3455
-----------------------------------------------------
Fax | 984-840-5900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 W THOMAS ST
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27804-5336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-345-3455
-----------------------------------------------------
Fax | 984-840-5900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------