Provider Demographics
NPI:1487476040
Name:FENDERSON, LATASHA YVETTE
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:YVETTE
Last Name:FENDERSON
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 1:320 ASTER LN
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-3549
Mailing Address - Country:US
Mailing Address - Phone:419-806-7706
Mailing Address - Fax:
Practice Address - Street 1:320 ASTER LN
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-3549
Practice Address - Country:US
Practice Address - Phone:419-806-7706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1487476040172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker