Healthcare Provider Details

I. General information

NPI: 1669606604
Provider Name (Legal Business Name): NICOLE MARIE LATTIMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28237 NEWHALL RANCH RD
VALENCIA CA
91355-0986
US

IV. Provider business mailing address

28237 NEWHALL RANCH RD
VALENCIA CA
91355-0986
US

V. Phone/Fax

Practice location:
  • Phone: 661-257-4242
  • Fax: 661-294-0020
Mailing address:
  • Phone: 661-257-4242
  • Fax: 661-294-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number63579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: