Healthcare Provider Details

I. General information

NPI: 1104126150
Provider Name (Legal Business Name): KATHLEEN DIANE WHITNEY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 CONGO RD
BENTON AR
72019-6913
US

IV. Provider business mailing address

6640 CONGO RD
BENTON AR
72019-6913
US

V. Phone/Fax

Practice location:
  • Phone: 501-794-4110
  • Fax: 501-316-9360
Mailing address:
  • Phone: 501-794-4110
  • Fax: 501-316-9360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03385 APN
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: