Provider Demographics
NPI:1366209678
Name:LAKE, LATOSHA SHANTA
Entity type:Individual
Prefix:MRS
First Name:LATOSHA
Middle Name:SHANTA
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATOSHA
Other - Middle Name:
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1424 REDBUD PL
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3147
Mailing Address - Country:US
Mailing Address - Phone:440-597-8150
Mailing Address - Fax:
Practice Address - Street 1:1424 REDBUD PL
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3147
Practice Address - Country:US
Practice Address - Phone:440-597-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare