Provider Demographics
NPI:1023203064
Name:WHALEY, MATTIE LAVON
Entity Type:Individual
Prefix:MS
First Name:MATTIE
Middle Name:LAVON
Last Name:WHALEY
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 1:29 BAPTIST DR
Mailing Address - Street 2:
Mailing Address - City:STAR CITY
Mailing Address - State:AR
Mailing Address - Zip Code:71667-8505
Mailing Address - Country:US
Mailing Address - Phone:870-718-7201
Mailing Address - Fax:
Practice Address - Street 1:29 BAPTIST DR
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667-8505
Practice Address - Country:US
Practice Address - Phone:870-718-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR3014230001Medicaid