Provider Demographics
NPI:1649845280
Name:LATHE, SUSAN MARIE (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:LATHE
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 1:1107 LONG CT
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1525
Mailing Address - Country:US
Mailing Address - Phone:309-281-9584
Mailing Address - Fax:
Practice Address - Street 1:1107 LONG CT
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1525
Practice Address - Country:US
Practice Address - Phone:309-281-9584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023290041.438653363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health