Healthcare Provider Details

I. General information

NPI: 1407039332
Provider Name (Legal Business Name): MRS. JOHANNA ALICIA LATHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date: 08/27/2026
Reactivation Date: 09/21/2026

III. Provider practice location address

1253 W I ST
LOS BANOS CA
93635-3930
US

IV. Provider business mailing address

1253 W I ST
LOS BANOS CA
93635-3930
US

V. Phone/Fax

Practice location:
  • Phone: 209-710-6333
  • Fax:
Mailing address:
  • Phone: 209-710-6333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number755647
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95038240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: