Provider Demographics
NPI:1164689998
Name:WHITEHORN, PAULA JEAN (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JEAN
Last Name:WHITEHORN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:WHITEHORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:172 JUSTICE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9354
Mailing Address - Country:US
Mailing Address - Phone:719-275-1626
Mailing Address - Fax:
Practice Address - Street 1:172 JUSTICE CENTER RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9354
Practice Address - Country:US
Practice Address - Phone:719-275-1626
Practice Address - Fax:719-275-4328
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43181163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07431810Medicaid