Provider Demographics
NPI:1487800710
Name:HAILES, LATONYA
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:HAILES
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 1:1507 HARDY ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4978
Mailing Address - Country:US
Mailing Address - Phone:601-410-5836
Mailing Address - Fax:888-449-9560
Practice Address - Street 1:128 DEER RUN RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-6205
Practice Address - Country:US
Practice Address - Phone:601-410-5836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0600X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02671051Medicaid