Healthcare Provider Details

I. General information

NPI: 1124353719
Provider Name (Legal Business Name): BRANDON LANE WHITLOCK AG-ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 HIGHLAND AVE STE 7
CLARKSTON WA
99403-2836
US

IV. Provider business mailing address

PO BOX 189
CLARKSTON WA
99403-0189
US

V. Phone/Fax

Practice location:
  • Phone: 509-758-1119
  • Fax:
Mailing address:
  • Phone: 509-758-1119
  • Fax: 509-758-1140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number65287
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61081911
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: