Provider Demographics
NPI:1386949188
Name:WHITAKER, CARLY COOPER (CRNA)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:COOPER
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 LEWIS HARGETT CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3590
Mailing Address - Country:US
Mailing Address - Phone:859-268-1030
Mailing Address - Fax:859-269-4120
Practice Address - Street 1:150 N EAGLE CREEK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1805
Practice Address - Country:US
Practice Address - Phone:859-268-1030
Practice Address - Fax:859-269-4120
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY085916367500000X
OH327216163W00000X
KY1123465163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100151350Medicaid
IN201012540Medicaid
000000702826OtherANTHEM
OH3128832Medicaid
611077369 129571685OtherHEALTHNET
611077369 129571685OtherHEALTHNET
000000702826OtherANTHEM
$$$$$$$$$00OtherBUREAU OF WORKERS COMP
OHP00927706Medicare PIN
OH8249761Medicare PIN
IN201012540Medicaid