Provider Demographics
NPI:1447452164
Name:LATHAM, CAROLYN P (NPP, RN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:P
Last Name:LATHAM
Suffix:
Gender:F
Credentials:NPP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 STARLIGHT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:STARLIGHT
Mailing Address - State:PA
Mailing Address - Zip Code:18461-1045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 VESTAL PKWY E STE 2W
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1966
Practice Address - Country:US
Practice Address - Phone:607-341-4950
Practice Address - Fax:607-341-4933
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400888363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY400888Medicaid