1750579876 NPI number — GWEN HATLEY WHITING APRN MS BC

Table of content: GWEN HATLEY WHITING APRN MS BC (NPI 1750579876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750579876 NPI number — GWEN HATLEY WHITING APRN MS BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITING
Provider First Name:
GWEN
Provider Middle Name:
HATLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN MS BC
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:
1750579876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1481 BAILEY FARM DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30064-5219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 CHASTAIN RD NW
Provider Second Line Business Practice Location Address:
#5200 HOUSE #52
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30144-5588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-423-6644
Provider Business Practice Location Address Fax Number:
770-499-3655
Provider Enumeration Date:
10/15/2007

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: 390200000X , with the licence number:  RN 167681 CNS/PMH , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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