Healthcare Provider Details

I. General information

NPI: 1548568926
Provider Name (Legal Business Name): COURTNEY KAY WHITTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WILLIS AVE APT #1
SYRACUSE NY
13204-1034
US

IV. Provider business mailing address

1101 WILLIS AVE APT #1
SYRACUSE NY
13204-1034
US

V. Phone/Fax

Practice location:
  • Phone: 704-713-2596
  • Fax:
Mailing address:
  • Phone: 704-713-2596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number193041
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number193041
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number193041
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number193041
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number193041
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: