=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962121632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WHITLEY WITHERSPOON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2022
-----------------------------------------------------
Last Update Date | 08/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6715 BUCKHURST TRL
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-571-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6715 BUCKHURST TRL
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-571-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT001999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------