Healthcare Provider Details

I. General information

NPI: 1053183756
Provider Name (Legal Business Name): WHITNEY POPPELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 02/05/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2162 HAVENWOOD TRL NE
BROOKHAVEN GA
30319-4018
US

IV. Provider business mailing address

2162 HAVENWOOD TRL NE
BROOKHAVEN GA
30319-4018
US

V. Phone/Fax

Practice location:
  • Phone: 229-224-5417
  • Fax:
Mailing address:
  • Phone: 229-224-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number250416
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number250416
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: