MEDICARE: DR. LATISE L HAIRSTON

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	374J00000X	Doula

General Provider Information

NPI Number	:	1376220343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LATISE L HAIRSTON

Provider Business Mailing Address
First Line	:	193 E MORRIS AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14214-1828
Country	:	US
Telephone Number	:	716-225-7966
Fax Number	:

Provider Business Practice Location Address
First Line	:	193 E MORRIS AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14214-1828
Country	:	US
Telephone Number	:	716-225-7966
Fax Number	:

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

Provider Enumeration Date	:	06/30/2023
Last Update Date	:	06/30/2023

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