Healthcare Provider Details

I. General information

NPI: 1336325679
Provider Name (Legal Business Name): MICHELLE WHITEHEAD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 CENTRAL DR
EAST DUBLIN GA
31027-7412
US

IV. Provider business mailing address

2121A BELLEVUE RD
DUBLIN GA
31021-2998
US

V. Phone/Fax

Practice location:
  • Phone: 478-488-3057
  • Fax:
Mailing address:
  • Phone: 478-272-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN184151
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN184151
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: