Provider Demographics
NPI:1255137857
Name:SKIPPER, LATRICE SAMONE (NDTR)
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:SAMONE
Last Name:SKIPPER
Suffix:
Gender:
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3904
Mailing Address - Country:US
Mailing Address - Phone:718-584-9000
Mailing Address - Fax:
Practice Address - Street 1:595 CALHOUN AVE APT 7C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-2844
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered