Healthcare Provider Details

I. General information

NPI: 1144376179
Provider Name (Legal Business Name): JUDITH ELAINE LATNER F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

PO BOX 649
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12253
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP9000
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number383630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: