Healthcare Provider Details

I. General information

NPI: 1962567255
Provider Name (Legal Business Name): JUDY FAYE LATTIMORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 HWY 65N
MCGEHEE AR
71654
US

IV. Provider business mailing address

PO BOX 214
MCGEHEE AR
71654
US

V. Phone/Fax

Practice location:
  • Phone: 870-222-3107
  • Fax: 870-222-6741
Mailing address:
  • Phone: 870-222-3803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR63251
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: