Provider Demographics
NPI:1245689157
Name:LATHAM, MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LATHAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 E BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-4284
Mailing Address - Country:US
Mailing Address - Phone:907-715-1540
Mailing Address - Fax:
Practice Address - Street 1:1701 N SEWARD MERIDIAN PKWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6682
Practice Address - Country:US
Practice Address - Phone:907-715-1540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101342225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist