Provider Demographics
NPI:1104126150
Name:WHITNEY, KATHLEEN DIANE (APN)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:DIANE
Last Name:WHITNEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6640 CONGO RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-6913
Mailing Address - Country:US
Mailing Address - Phone:501-794-4110
Mailing Address - Fax:501-316-9360
Practice Address - Street 1:6640 CONGO RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-6913
Practice Address - Country:US
Practice Address - Phone:501-794-4110
Practice Address - Fax:501-316-9360
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03385 APN363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily