Healthcare Provider Details

I. General information

NPI: 1568700490
Provider Name (Legal Business Name): ANNA ELIZABETH WHITTINGTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7960 N. WICKHAM ROAD SUITE 103
MELBOURNE FL
32940-8096
US

IV. Provider business mailing address

7960 N. WICKHAM ROAD SUITE 103
MELBOURNE FL
32940-8096
US

V. Phone/Fax

Practice location:
  • Phone: 321-428-4737
  • Fax: 321-241-6457
Mailing address:
  • Phone: 321-428-4737
  • Fax: 321-241-6457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2445
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9107492
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: