Provider Demographics
NPI:1548691736
Name:LATHAM, HEATHER WENDY ELIZABETH
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:WENDY ELIZABETH
Last Name:LATHAM
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 1:250 S G ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3320
Mailing Address - Country:US
Mailing Address - Phone:909-651-7510
Mailing Address - Fax:
Practice Address - Street 1:250 S G ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3320
Practice Address - Country:US
Practice Address - Phone:909-651-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60436140363LF0000X
CA95017941363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily