Provider Demographics
NPI:1366814196
Name:PETRY, LATORSHA E
Entity type:Individual
Prefix:MRS
First Name:LATORSHA
Middle Name:E
Last Name:PETRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 CAYMAN BEND LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-1865
Mailing Address - Country:US
Mailing Address - Phone:409-550-9784
Mailing Address - Fax:
Practice Address - Street 1:1920 CAYMAN BEND LN
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-1865
Practice Address - Country:US
Practice Address - Phone:409-550-9784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47-5033066347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle