Provider Demographics
NPI:1194956672
Name:LATTA, SHANNON MICHAL (ARNP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHAL
Last Name:LATTA
Suffix:
Gender:F
Credentials:ARNP
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:4420 76TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3726
Practice Address - Country:US
Practice Address - Phone:360-651-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-02
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60098107363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9662628Medicaid
WA0254476OtherLABOR & INDUSTRIES
WA2003611Medicaid
WA0254476OtherLABOR & INDUSTRIES
WAG8909277Medicare PIN