Provider Demographics
NPI:1245808732
Name:LATTIE, GWENDOLYN
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:LATTIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 IMPERIAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6556
Mailing Address - Country:US
Mailing Address - Phone:301-665-9098
Mailing Address - Fax:
Practice Address - Street 1:1165 IMPERIAL DR STE 300
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6556
Practice Address - Country:US
Practice Address - Phone:301-665-9098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR152199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily