Provider Demographics
NPI:1871273615
Name:BERRY, LATONYA
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:BERRY
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 1:4637 VIENNA CHURCH RD LOT 1
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7516
Mailing Address - Country:US
Mailing Address - Phone:229-630-5878
Mailing Address - Fax:
Practice Address - Street 1:4637 VIENNA CHURCH RD LOT 1
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7516
Practice Address - Country:US
Practice Address - Phone:229-630-5878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAO-009592253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care