Healthcare Provider Details

I. General information

NPI: 1275643710
Provider Name (Legal Business Name): LATANYA P. FYNE D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 CENTRAL AVE.
AUGUSTA GA
30904-5850
US

IV. Provider business mailing address

1710 CENTRAL AVE.
AUGUSTA GA
30904-5850
US

V. Phone/Fax

Practice location:
  • Phone: 706-373-4402
  • Fax: 706-364-8628
Mailing address:
  • Phone: 706-373-4402
  • Fax: 706-364-8628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000619
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number000619
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: