Provider Demographics
NPI:1699907857
Name:WHITTENBURG, NICOLE (DPH)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:WHITTENBURG
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 OLD MOUNT HELEN RD
Mailing Address - Street 2:
Mailing Address - City:ALLARDT
Mailing Address - State:TN
Mailing Address - Zip Code:38504-5034
Mailing Address - Country:US
Mailing Address - Phone:931-456-7647
Mailing Address - Fax:
Practice Address - Street 1:265 HIGHLAND SQ
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-5105
Practice Address - Country:US
Practice Address - Phone:934-456-7647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist