Provider Demographics
NPI:1043425259
Name:LATTA, WINONA FAY (RN,BSN)
Entity Type:Individual
Prefix:MRS
First Name:WINONA
Middle Name:FAY
Last Name:LATTA
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5235 N TOSCANA AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3509
Mailing Address - Country:US
Mailing Address - Phone:208-855-0709
Mailing Address - Fax:208-855-0709
Practice Address - Street 1:5235 N TOSCANA AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3509
Practice Address - Country:US
Practice Address - Phone:208-855-0709
Practice Address - Fax:208-855-0709
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-35643163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy