Provider Demographics
NPI:1316259203
Name:WHITLOCK, MICKI LEE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:MICKI
Middle Name:LEE
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-5062
Mailing Address - Country:US
Mailing Address - Phone:423-543-7919
Mailing Address - Fax:
Practice Address - Street 1:2521 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-5062
Practice Address - Country:US
Practice Address - Phone:423-543-7919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15083363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily