Provider Demographics
NPI:1073046314
Name:HUSTON, WHITNEY YOLANDA
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:YOLANDA
Last Name:HUSTON
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 1:401 CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-5740
Mailing Address - Country:US
Mailing Address - Phone:912-271-7446
Mailing Address - Fax:
Practice Address - Street 1:401 CHRISTOPHER DR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-5740
Practice Address - Country:US
Practice Address - Phone:912-271-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA335E00000X
GA1744P3200X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1744P3200XMedicaid