MEDICARE: MS. LATWANSHREE QUEEN KIDD

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	225400000X	Rehabilitation Practitioner
2	225500000X	Respiratory/Developmental/Rehabilitative Specialist/Technologist

General Provider Information

NPI Number	:	1992100564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATWANSHREE QUEEN KIDD

Provider Business Mailing Address
First Line	:	21 W OWENS AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-6817
Country	:	US
Telephone Number	:	323-817-8558
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 W OWENS AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-6817
Country	:	US
Telephone Number	:	323-817-8558
Fax Number	:

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

Provider Enumeration Date	:	10/24/2014
Last Update Date	:	10/24/2014

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