Provider Demographics
NPI:1649224783
Name:LATA, LAURA JEAN (ANP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:LATA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 W MILL AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2444
Mailing Address - Country:US
Mailing Address - Phone:208-664-3301
Mailing Address - Fax:877-653-2694
Practice Address - Street 1:810 N. SIXTH AVENUE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-265-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1047A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDML0709571OtherDEA
CTML0709571OtherDEA