Provider Demographics
NPI:1194046961
Name:LATTIMORE, WILLIE LEE (NP)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:LEE
Last Name:LATTIMORE
Suffix:
Gender:M
Credentials:NP
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 408
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-0408
Mailing Address - Country:US
Mailing Address - Phone:706-354-5770
Mailing Address - Fax:706-354-5769
Practice Address - Street 1:902 N 7TH ST # 100
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3234
Practice Address - Country:US
Practice Address - Phone:229-276-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102042363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner