Healthcare Provider Details

I. General information

NPI: 1104741636
Provider Name (Legal Business Name): PAIGE LATHAM RN, BSN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAIGE DIDORA

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 LASALLE AVE STE 2800
MINNEAPOLIS MN
55402-2039
US

IV. Provider business mailing address

3908 PARK AVE
MINNEAPOLIS MN
55407-2542
US

V. Phone/Fax

Practice location:
  • Phone: 612-349-0660
  • Fax:
Mailing address:
  • Phone: 952-484-5601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1959765
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: