=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831492123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDANA LEANNE LATOZAS RN, MSN, CCRN, ACNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2010
-----------------------------------------------------
Last Update Date | 05/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1330 GRAND BLANC
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-464-0887
-----------------------------------------------------
Fax | 734-402-0254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36115 SCHOOLCRAFT RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-464-0887
-----------------------------------------------------
Fax | 734-402-0254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 4704253776
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 4704253776
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 4704253776
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------