=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063513133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARLA KAY WHITED MOA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 GAS PLANT ROAD REA CLINIC DUQUOIN
-----------------------------------------------------
City | DUQUOIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-542-8702
-----------------------------------------------------
Fax | 618-542-8792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 155 REA CLINIC
-----------------------------------------------------
City | CHRISTOPHER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-724-2401
-----------------------------------------------------
Fax | 618-724-2571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------