Provider Demographics
NPI:1013380948
Name:LATIMER, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:LATIMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 STATE HIGHWAY 150 SOUTH
Mailing Address - Street 2:SUITE J
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5307
Mailing Address - Country:US
Mailing Address - Phone:307-789-7915
Mailing Address - Fax:307-789-6009
Practice Address - Street 1:1575 STATE HIGHWAY 150 SOUTH
Practice Address - Street 2:SUITE J
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5307
Practice Address - Country:US
Practice Address - Phone:307-789-7915
Practice Address - Fax:307-789-6009
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker