Healthcare Provider Details

I. General information

NPI: 1487623682
Provider Name (Legal Business Name): DAVID E LATHAM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 TUSCULUM BLVD SUITE 114
GREENEVILLE TN
37745-4091
US

IV. Provider business mailing address

PO BOX 896138
CHARLOTTE NC
28289-6138
US

V. Phone/Fax

Practice location:
  • Phone: 423-639-0941
  • Fax: 423-638-3401
Mailing address:
  • Phone: 423-639-0941
  • Fax: 423-638-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN0000039907
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8864
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: