Provider Demographics
NPI:1932521200
Name:LATKA, KERRY HANNIFIN (ARNP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:HANNIFIN
Last Name:LATKA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HEALTH PARK BLVD
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3707
Mailing Address - Country:US
Mailing Address - Phone:904-824-8666
Mailing Address - Fax:904-824-8933
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 4000
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3707
Practice Address - Country:US
Practice Address - Phone:904-824-8666
Practice Address - Fax:904-824-8933
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9173044363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010393000Medicaid
FLHR121ZMedicare PIN