1356383855 NPI number — MRS. LATARSHA SELWYNA CHEATHAM FNP-BC

Table of content: MRS. LATARSHA SELWYNA CHEATHAM FNP-BC (NPI 1356383855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356383855 NPI number — MRS. LATARSHA SELWYNA CHEATHAM FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEATHAM
Provider First Name:
LATARSHA
Provider Middle Name:
SELWYNA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356383855
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12310 BROKEN CREEK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77584-9730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-993-4293
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6720 BERTNER ST
Provider Second Line Business Practice Location Address:
MC 4-278 BOX 112
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-2604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-785-8537
Provider Business Practice Location Address Fax Number:
832-355-6865
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  673237 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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