Provider Demographics
NPI:1083994404
Name:WHITLEY, GEOFFREY (FNP)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 NEW STATE HWY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-5460
Mailing Address - Country:US
Mailing Address - Phone:508-880-6868
Mailing Address - Fax:508-880-6848
Practice Address - Street 1:C8 SHIPWAY PL
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-4301
Practice Address - Country:US
Practice Address - Phone:325-439-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2267850363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
02354878987OtherPRIVATE PAYERS