Provider Demographics
NPI:1437035029
Name:LATCHISON, CHETARA
Entity type:Individual
Prefix:
First Name:CHETARA
Middle Name:
Last Name:LATCHISON
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 1:201 W BROADWAY STE 3C
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-3842
Mailing Address - Country:US
Mailing Address - Phone:573-476-6416
Mailing Address - Fax:573-476-6417
Practice Address - Street 1:201 W BROADWAY STE 3C
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3842
Practice Address - Country:US
Practice Address - Phone:573-476-6416
Practice Address - Fax:573-476-6417
Is Sole Proprietor?:No
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOM208357015172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO99-3884284OtherNEMT