Healthcare Provider Details

I. General information

NPI: 1730743170
Provider Name (Legal Business Name): COURTNEY WHITELOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE STE 655
LANSING MI
48912-1837
US

IV. Provider business mailing address

1200 E MICHIGAN AVE STE 655
LANSING MI
48912-1837
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4351047590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: