Provider Demographics
NPI:1841722469
Name:LATTERELL, BRYNNE RAINIER WILSON (MD, MPH)
Entity type:Individual
Prefix:
First Name:BRYNNE
Middle Name:RAINIER WILSON
Last Name:LATTERELL
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 UPLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4485
Mailing Address - Country:US
Mailing Address - Phone:952-993-1440
Mailing Address - Fax:
Practice Address - Street 1:9555 UPLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4485
Practice Address - Country:US
Practice Address - Phone:952-993-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-02
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS2017-0338390200000X
NM390200000X
MN67086207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program