Healthcare Provider Details

I. General information

NPI: 1932708146
Provider Name (Legal Business Name): LATROY OMAR DINGLE APRN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 E STONE AVE FL 12
GREENVILLE SC
29609-5671
US

IV. Provider business mailing address

PO BOX 211699
EAGAN MN
55121-3699
US

V. Phone/Fax

Practice location:
  • Phone: 866-849-0692
  • Fax: 888-973-8821
Mailing address:
  • Phone: 866-849-0692
  • Fax: 888-973-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number24151
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: