MEDICARE: MARY LEE WHITTEN CPNP

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	363LP0200X	Pediatric Nurse Practitioner	334831	CA

General Provider Information

NPI Number	:	1497704233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LEE WHITTEN CPNP

Provider Business Mailing Address
First Line	:	12856 HOMERIDGE LN
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-1047
Country	:	US
Telephone Number	:	909-673-9125
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501A S BON VIEW AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-4408
Country	:	US
Telephone Number	:	909-673-9125
Fax Number	:	909-673-1676

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

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	10/05/2011

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