Basic Information
| Provider Information | |||||||||
| NPI: | 1700339074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATTA | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | CARLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 85 SOUTH WEST STREET | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24 ALBRO RD | ||||||||
| Address2: | |||||||||
| City: | MARATHON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138032808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2016 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 340806 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.