=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619551850
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATONYA HOLMES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2021
-----------------------------------------------------
Last Update Date | 05/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7002 HODGSON MEMORIAL DR STE 113
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31406-2586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-272-4267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1355 BRADLEY BLVD APT 709
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31419-8160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-272-4267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247ZC0005X
-----------------------------------------------------
Taxonomy Name | Clinical Laboratory Director (Non-physician)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | LPN064789
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | LPN064789
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------