Provider Demographics
NPI:1194291179
Name:LATHAM, DALTON ENRICO (NP- NURSE PRACTITION)
Entity type:Individual
Prefix:MR
First Name:DALTON
Middle Name:ENRICO
Last Name:LATHAM
Suffix:
Gender:M
Credentials:NP- NURSE PRACTITION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:8521 KEPHART LANE
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103
Mailing Address - Country:US
Mailing Address - Phone:269-277-3260
Mailing Address - Fax:
Practice Address - Street 1:8521 KEPHART LANE
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103
Practice Address - Country:US
Practice Address - Phone:269-277-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704211443363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily