Provider Demographics
NPI:1356931224
Name:LATTY, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:LATTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 WHITE WATER BAY DR
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-8128
Mailing Address - Country:US
Mailing Address - Phone:347-414-4781
Mailing Address - Fax:
Practice Address - Street 1:1124 WHITE WATER BAY DR
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-8128
Practice Address - Country:US
Practice Address - Phone:347-414-4781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9343556363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner