Provider Demographics
NPI:1982172573
Name:LATHAM, MIKAYLA MARY (NP)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:MARY
Last Name:LATHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:MARY
Other - Last Name:BIRTHRONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1302 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3419
Practice Address - Country:US
Practice Address - Phone:336-475-6139
Practice Address - Fax:336-475-3331
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50111833363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner