MEDICARE: LATISHA ANN HAWKINS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	957386	TX

General Provider Information

NPI Number	:	1053913103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATISHA ANN HAWKINS RN

Provider Business Mailing Address
First Line	:	6925 LOMA VISTA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6428
Country	:	US
Telephone Number	:	817-323-3309
Fax Number	:

Provider Business Practice Location Address
First Line	:	6925 LOMA VISTA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-6428
Country	:	US
Telephone Number	:	817-323-3309
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2020
Last Update Date	:	11/13/2020

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