1144691064 NPI number — MRS. ROSELYN WHITLEY MA, PLPC

Table of content: MRS. ROSELYN WHITLEY MA, PLPC (NPI 1144691064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144691064 NPI number — MRS. ROSELYN WHITLEY MA, PLPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITLEY
Provider First Name:
ROSELYN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, PLPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144691064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11814 MARKET PLACE AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-6084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-223-6153
Provider Business Mailing Address Fax Number:
225-246-2420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 FERNWOOD DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-3130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-923-3733
Provider Business Practice Location Address Fax Number:
225-923-3735
Provider Enumeration Date:
10/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 600720433 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600964601 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600751961 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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