MEDICARE: LATANIA R SMITH-WASHINGTON

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1083380232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATANIA R SMITH-WASHINGTON

Provider Business Mailing Address
First Line	:	14333 BEACH BLVD STE 33
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-1573
Country	:	US
Telephone Number	:	904-378-6405
Fax Number	:

Provider Business Practice Location Address
First Line	:	14333 BEACH BLVD STE 33
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-1573
Country	:	US
Telephone Number	:	904-378-6405
Fax Number	:

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

Provider Enumeration Date	:	08/18/2021
Last Update Date	:	09/01/2021

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