Provider Demographics
NPI:1730859646
Name:KELLY, LATASHA (LATASHA KELLY)
Entity type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LATASHA KELLY
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LATASHA KELLY
Mailing Address - Street 1:41 EMERALD WAY
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-1779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41 EMERALD WAY
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-1779
Practice Address - Country:US
Practice Address - Phone:937-806-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSR174894172A00000X
OH372600000X, 376J00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker