Healthcare Provider Details

I. General information

NPI: 1659763589
Provider Name (Legal Business Name): KENDRA LEAH LATTY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 BAKER ST
COSTA MESA CA
92626-4111
US

IV. Provider business mailing address

1150 BAKER ST
COSTA MESA CA
92626-4111
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95010674
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP128102
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: