Provider Demographics
NPI:1790200020
Name:LATTEN, KERRIANN (NP)
Entity Type:Individual
Prefix:
First Name:KERRIANN
Middle Name:
Last Name:LATTEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HWY BLDG 14
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-689-6226
Mailing Address - Fax:631-675-0736
Practice Address - Street 1:2500 NESCONSET HWY BLDG 14
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:316-896-2266
Practice Address - Fax:631-675-0736
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342196363LF0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04966625Medicaid