=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487690236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIA LATHAM NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 4TH ST SUITE 3B100
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79430-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-743-2340
-----------------------------------------------------
Fax | 806-743-1775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5865
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79408-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-743-2898
-----------------------------------------------------
Fax | 806-743-2787
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 547826
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------