Provider Demographics
NPI:1205209962
Name:WHITEHEAD, MARY (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16866
Mailing Address - Country:US
Mailing Address - Phone:814-342-2333
Mailing Address - Fax:814-342-2277
Practice Address - Street 1:601 N FRONT ST
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-2303
Practice Address - Country:US
Practice Address - Phone:814-342-2333
Practice Address - Fax:814-342-2277
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010179363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP010179OtherSTATE LICENSE