Healthcare Provider Details

I. General information

NPI: 1700042793
Provider Name (Legal Business Name): MILDRED R WHITLEY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11517 KANIS RD
LITTLE ROCK AR
72211-3724
US

IV. Provider business mailing address

13817 ABINGER CT
LITTLE ROCK AR
72212-3736
US

V. Phone/Fax

Practice location:
  • Phone: 501-993-8707
  • Fax: 501-223-8075
Mailing address:
  • Phone: 501-219-2202
  • Fax: 501-223-8075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberPT 2087
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: