MEDICARE: LATASHA DUPRIEST-WILLIAMS CBRF/DIRECTOR

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	172A00000X	Driver	D1625368564808	WI

General Provider Information

NPI Number	:	1821532805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATASHA DUPRIEST-WILLIAMS CBRF/DIRECTOR

Provider Business Mailing Address
First Line	:	4054 N 71ST ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-1026
Country	:	US
Telephone Number	:	414-758-8382
Fax Number	:

Provider Business Practice Location Address
First Line	:	4054 N 71ST ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-1026
Country	:	US
Telephone Number	:	414-758-8382
Fax Number	:

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

Provider Enumeration Date	:	12/11/2016
Last Update Date	:	12/11/2016

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