Provider Demographics
NPI:1114099041
Name:LATHAM, VICKI LEGRAND (CNM)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:LEGRAND
Last Name:LATHAM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 NORTHLINE AVE.
Mailing Address - Street 2:STE 130
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7600
Mailing Address - Country:US
Mailing Address - Phone:336-286-6565
Mailing Address - Fax:336-286-6566
Practice Address - Street 1:3200 NORTHLINE AVE.
Practice Address - Street 2:STE 130
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7600
Practice Address - Country:US
Practice Address - Phone:336-286-6565
Practice Address - Fax:336-286-6566
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC165367A00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7821OtherACNM CERTIFICATE NUMBER