MEDICARE: LATRICE WADDELL CNS-PMH

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	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	APRN.CNS.15185	OH
2	163W00000X	Registered Nurse	RN.344000	OH
3	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	0024196812	VA
4	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	COA15185NS	OH
5	163W00000X	Registered Nurse	4704413076	MI
6	363L00000X	Nurse Practitioner	4704413076	MI

General Provider Information

NPI Number	:	1316375124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATRICE WADDELL CNS-PMH

Provider Business Mailing Address
First Line	:	1425 STARR AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43605-2456
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 STARR AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43605
Country	:	US
Telephone Number	:	419-693-0631
Fax Number	:	419-936-7606

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

Provider Enumeration Date	:	10/15/2013
Last Update Date	:	03/27/2026

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