Healthcare Provider Details

I. General information

NPI: 1316930795
Provider Name (Legal Business Name): JANIS J WHITEHEAD RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 N 6TH ST
POMEROY WA
99347-9705
US

IV. Provider business mailing address

1808 WHEATLANDS AVE
LEWISTON ID
83501-9407
US

V. Phone/Fax

Practice location:
  • Phone: 509-843-1591
  • Fax: 509-843-1234
Mailing address:
  • Phone: 309-252-1084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209001099
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60594743
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number56229
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: