Provider Demographics
NPI:1003598368
Name:LATHROP, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LATHROP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 BLACKBEARD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1139
Mailing Address - Country:US
Mailing Address - Phone:904-238-0070
Mailing Address - Fax:
Practice Address - Street 1:2449 BLACKBEARD DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1139
Practice Address - Country:US
Practice Address - Phone:904-238-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9415770163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse