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Individual

LATISHIA KING

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
LPN

Contact information

Practice address
139 HENRY PKWY, MCDONOUGH, GA 30253-6636
(770) 358-5252
(770) 898-7412
Mailing address
202 PINEVIEW DR, THOMASTON, GA 30286-2309
(706) 975-9655

Taxonomy

Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
LPN092595
GA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
2199LK
BCBS
GA
Enumeration date
02/09/2021
Last updated
02/09/2021
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