Provider Demographics
NPI:1558483727
Name:LATHAN, CAROLYN LOUISE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:LOUISE
Last Name:LATHAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7020 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3947
Mailing Address - Country:US
Mailing Address - Phone:262-652-1001
Mailing Address - Fax:
Practice Address - Street 1:7020 36TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3947
Practice Address - Country:US
Practice Address - Phone:262-652-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21256031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39865800OtherPROVIDER NUMBER