=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710114517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | XENA ANTOINETTE WHITTIER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2009
-----------------------------------------------------
Last Update Date | 09/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 CHURCH ST NE
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-7220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-420-1690
-----------------------------------------------------
Fax | 770-420-1661
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 CHURCH ST NE
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-7220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-420-1690
-----------------------------------------------------
Fax | 770-420-1661
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 074620
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------