Provider Demographics
NPI:1366742090
Name:BEATTY, LATONYA ROCHELLE (MD)
Entity type:Individual
Prefix:MS
First Name:LATONYA
Middle Name:ROCHELLE
Last Name:BEATTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2523 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6003
Practice Address - Country:US
Practice Address - Phone:910-763-5522
Practice Address - Fax:910-763-0413
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-01853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1366742090OtherNPI
NC7004963Medicaid