Provider Demographics
NPI:1114995123
Name:LATHAM, ELIZABETH G (FNP-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:G
Last Name:LATHAM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-9675
Mailing Address - Fax:928-645-2626
Practice Address - Street 1:467 VISTA AVE.
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-1625
Practice Address - Country:US
Practice Address - Phone:928-645-8123
Practice Address - Fax:928-645-3862
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN067045/AP0855363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ645252Medicaid
AZ645252Medicaid
AZ68615, 68616, 68617Medicare ID - Type Unspecified