Provider Demographics
NPI:1487837001
Name:LATSCH, ELLEN MAUREEN (CNP RNC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MAUREEN
Last Name:LATSCH
Suffix:
Gender:F
Credentials:CNP RNC
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MAUREEN
Other - Last Name:FONVILLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP RNC
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:2116 CRAIG RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6149
Practice Address - Country:US
Practice Address - Phone:715-858-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI521363LX0001X
MNR1692077163W00000X
MNLAT104292845363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43835900Medicaid
WI0511-20270Medicare PIN