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General NPI Number Information
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NPI Number | 1962163105
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Entity Type | Individual
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Provider Name | LATRESHA ROCHELLE WADE NP
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Gender | Female
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Dates
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Enumeration Date | 01/09/2022
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Last Update Date | 01/09/2022
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Provider Practice Location Address
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Address Line | 14 TREVINO CV
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City | LITTLE ROCK
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State | AR
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Zip | 72210-9107
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Country | US
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Telephone | 501-416-0117
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Fax |
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Provider Business Mailing Address
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Address Line | 4704 W COMMERCIAL DR STE A
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City | NORTH LITTLE ROCK
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State | AR
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Zip | 72116-8040
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Country | US
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Telephone | 501-416-0117
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 217904
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License Number State | AR
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