Provider Demographics
NPI:1568738656
Name:LATHAM, SUSAN JEAN (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:LATHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:JEAN
Other - Last Name:MARESCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1150 W CAPITOL DR
Mailing Address - Street 2:#100
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-5015
Mailing Address - Country:US
Mailing Address - Phone:310-514-1972
Mailing Address - Fax:310-514-1972
Practice Address - Street 1:1534 W 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-4402
Practice Address - Country:US
Practice Address - Phone:310-548-5656
Practice Address - Fax:310-548-5242
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA193930163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse