MEDICARE: DESTINEE LATHON CNA

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	376K00000X	Nurse's Aide

General Provider Information

NPI Number	:	1851992622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINEE LATHON CNA

Provider Business Mailing Address
First Line	:	1731 FAIRMONT DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62702-2927
Country	:	US
Telephone Number	:	217-953-1004
Fax Number	:

Provider Business Practice Location Address
First Line	:	1731 FAIRMONT DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62702-2927
Country	:	US
Telephone Number	:	217-953-1004
Fax Number	:

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

Provider Enumeration Date	:	11/06/2020
Last Update Date	:	11/06/2020

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Directions to “ DESTINEE LATHON CNA” Practice Location

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