Provider Demographics
NPI:1053921148
Name:ALLEN, LATISHA
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 N STATE ST APT D1
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3247
Mailing Address - Country:US
Mailing Address - Phone:815-491-0603
Mailing Address - Fax:
Practice Address - Street 1:479 N STATE ST APT D1
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3247
Practice Address - Country:US
Practice Address - Phone:815-491-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management