Healthcare Provider Details

I. General information

NPI: 1205209962
Provider Name (Legal Business Name): MARY WHITEHEAD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N FRONT ST
PHILIPSBURG PA
16866-2303
US

IV. Provider business mailing address

601 N FRONT STREET
PHILIPSBURG PA
16866
US

V. Phone/Fax

Practice location:
  • Phone: 814-342-2333
  • Fax: 814-342-2277
Mailing address:
  • Phone: 814-342-2333
  • Fax: 814-342-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP010179
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: