Provider Demographics
NPI:1093721037
Name:WHITLEY, DEAN E (NP)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:E
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2742
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-2742
Mailing Address - Country:US
Mailing Address - Phone:601-853-8814
Mailing Address - Fax:601-853-8816
Practice Address - Street 1:794 HIGHWAY 51
Practice Address - Street 2:SUITE D
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-9662
Practice Address - Country:US
Practice Address - Phone:601-853-8814
Practice Address - Fax:601-853-8816
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR613053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01656530Medicaid
MS500001655Medicare ID - Type Unspecified
MS01656530Medicaid