Healthcare Provider Details

I. General information

NPI: 1346150919
Provider Name (Legal Business Name): MADELYN LATTYAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N JACKSON ST STE 100A
TULLAHOMA TN
37388-8259
US

IV. Provider business mailing address

121 BURLCREST CT
MERIDIANVILLE AL
35759-1669
US

V. Phone/Fax

Practice location:
  • Phone: 931-393-7831
  • Fax:
Mailing address:
  • Phone: 724-977-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: