=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225516354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITEHEAD WOUND CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2018
-----------------------------------------------------
Last Update Date | 07/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 HIGHWAY 51 N
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39601-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-835-9444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 756
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39631-0756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-395-2585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP-C
-----------------------------------------------------
Name | MRS. LESA COLLEEN WHITEHEAD
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 601-395-2585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R853722
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------