Provider Demographics
NPI:1225498090
Name:LATHAM, AMY DAWN (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DAWN
Last Name:LATHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 TOMBRAS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-2720
Mailing Address - Country:US
Mailing Address - Phone:423-867-4969
Mailing Address - Fax:423-867-4971
Practice Address - Street 1:1508 TOMBRAS AVE
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-2720
Practice Address - Country:US
Practice Address - Phone:423-867-4969
Practice Address - Fax:423-867-4971
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN207710363LF0000X
TN22136363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I507712Medicare PIN
TN1035024I23Medicare PIN