Healthcare Provider Details

I. General information

NPI: 1780459032
Provider Name (Legal Business Name): ANTHONY WHITLOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 11/16/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 CLARA ANN RD
LAVALETTE WV
25535
US

IV. Provider business mailing address

PO BOX 1104
LAVALETTE WV
25535-1104
US

V. Phone/Fax

Practice location:
  • Phone: 304-730-9243
  • Fax:
Mailing address:
  • Phone: 304-730-9243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: