Provider Demographics
NPI:1548024144
Name:STEVENSON, LATOSHA
Entity type:Individual
Prefix:MRS
First Name:LATOSHA
Middle Name:
Last Name:STEVENSON
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 1:9605 BLOM BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-4703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9605 BLOM BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-4703
Practice Address - Country:US
Practice Address - Phone:318-286-7991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1072127163WG0000X
LA242857363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice