Healthcare Provider Details

I. General information

NPI: 1992514574
Provider Name (Legal Business Name): WHITNEY LYNN WHITLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

120 MULBERRY DR
SENOIA GA
30276-1344
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1000
  • Fax:
Mailing address:
  • Phone: 770-676-8528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209822
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: