Healthcare Provider Details

I. General information

NPI: 1801224043
Provider Name (Legal Business Name): KATHERINE WHITLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE WHITLEY RN

II. Dates (important events)

Enumeration Date: 10/25/2013
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 N DUTTON AVE #275
SANTA ROSA CA
95401-4659
US

IV. Provider business mailing address

1260 N DUTTON AVE #275
SANTA ROSA CA
95401-4659
US

V. Phone/Fax

Practice location:
  • Phone: 707-206-7268
  • Fax: 707-206-7254
Mailing address:
  • Phone: 707-206-7268
  • Fax: 707-206-7254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number824671
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2014010936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: