=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952105074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNEKA LATHAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2025
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 181 W COMMERCE DR
-----------------------------------------------------
City | HAYDEN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83835-9221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-696-1330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 S CARPENTER LOOP
-----------------------------------------------------
City | POST FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83854-5748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-219-8219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 2671639
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------