Provider Demographics
NPI:1679017206
Name:SIMON, LATRALL
Entity type:Individual
Prefix:
First Name:LATRALL
Middle Name:
Last Name:SIMON
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 1:12458 CONDOR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-3711
Mailing Address - Country:US
Mailing Address - Phone:904-508-2687
Mailing Address - Fax:904-379-5457
Practice Address - Street 1:12458 CONDOR DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-3711
Practice Address - Country:US
Practice Address - Phone:904-508-2687
Practice Address - Fax:904-379-5457
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001477397Medicaid