Provider Demographics
NPI:1144715590
Name:LATHAN, KYLE T
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:T
Last Name:LATHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 MARQUETTE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1935
Mailing Address - Country:US
Mailing Address - Phone:505-508-7293
Mailing Address - Fax:
Practice Address - Street 1:903 MARQUETTE AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1935
Practice Address - Country:US
Practice Address - Phone:505-508-7293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist