1356896088 NPI number — MRS. ANTONIETTE LATASHA RATLIFF

Table of content: MRS. ANTONIETTE LATASHA RATLIFF (NPI 1356896088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356896088 NPI number — MRS. ANTONIETTE LATASHA RATLIFF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RATLIFF
Provider First Name:
ANTONIETTE
Provider Middle Name:
LATASHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RATLIFF
Provider Other First Name:
TASHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356896088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6802
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33508-6013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-495-4276
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 E 7TH AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33605-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-495-4276
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2016

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: 101YM0800X , with the licence number:  IMH 14709 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 164W00000X , with the licence number: PN 5198859 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 116717700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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