Provider Demographics
NPI:1477645976
Name:WHITLEY, LATONYA (DNP, MHA, MS)
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:DNP, MHA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MARYLAND AVE W
Mailing Address - Street 2:APT 208
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4160
Mailing Address - Country:US
Mailing Address - Phone:612-701-4301
Mailing Address - Fax:
Practice Address - Street 1:17650 134TH AVE SE
Practice Address - Street 2:S201
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-6889
Practice Address - Country:US
Practice Address - Phone:612-701-4301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1585841363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN642452000Medicaid
MN642452000Medicaid