Provider Demographics
NPI:1306248604
Name:LATHREM, MARY SANDRA (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SANDRA
Last Name:LATHREM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:940 BOB KIRBY RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-1910
Mailing Address - Country:US
Mailing Address - Phone:859-699-9534
Mailing Address - Fax:
Practice Address - Street 1:256 FORT SANDERS WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3355
Practice Address - Country:US
Practice Address - Phone:859-699-9534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008752367500000X
FLAPRN9284688367500000X
TN38874367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered