Provider Demographics
NPI:1154894426
Name:WHITLOCK, KRISTIN FAYE
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:FAYE
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SUMMIT HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLSON
Mailing Address - State:GA
Mailing Address - Zip Code:30565-3252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:421 SUMMIT HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:NICHOLSON
Practice Address - State:GA
Practice Address - Zip Code:30565-3252
Practice Address - Country:US
Practice Address - Phone:706-410-8409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer