Provider Demographics
NPI:1063513133
Name:WHITED, KARLA KAY (MOA)
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:KAY
Last Name:WHITED
Suffix:
Gender:F
Credentials:MOA
Other - Prefix:
Other - First Name:KARLA
Other - Middle Name:KAY
Other - Last Name:RUNGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:REA CLINIC
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-2571
Practice Address - Street 1:119 GAS PLANT ROAD
Practice Address - Street 2:REA CLINIC DUQUOIN
Practice Address - City:DUQUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832
Practice Address - Country:US
Practice Address - Phone:618-542-8702
Practice Address - Fax:618-542-8792
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical