Provider Demographics
NPI:1336973908
Name:WHITLOCK, STEPHANIE P (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:P
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 13TH STREET D
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5704
Mailing Address - Country:US
Mailing Address - Phone:208-305-0742
Mailing Address - Fax:
Practice Address - Street 1:1119 HIGHLAND AVE STE 10
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2836
Practice Address - Country:US
Practice Address - Phone:509-758-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61601853363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology