Provider Demographics
NPI:1245014299
Name:HINES, LATASHA DEREE (AGACNP)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:DEREE
Last Name:HINES
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:DEREE
Other - Last Name:HARDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2036 CHARTERHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8017
Mailing Address - Country:US
Mailing Address - Phone:252-560-2435
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHINE-3CL25363LA2100X
NC5018669363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care