MEDICARE: MS. KATHLEEN DIANE WHITNEY APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	A03385 APN	AR

General Provider Information

NPI Number	:	1104126150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHLEEN DIANE WHITNEY APN

Provider Business Mailing Address
First Line	:	6640 CONGO RD
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-6913
Country	:	US
Telephone Number	:	501-794-4110
Fax Number	:	501-316-9360

Provider Business Practice Location Address
First Line	:	6640 CONGO RD
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-6913
Country	:	US
Telephone Number	:	501-794-4110
Fax Number	:	501-316-9360

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2010
Last Update Date	:	10/25/2010

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