Provider Demographics
NPI:1225516354
Name:WHITEHEAD WOUND CARE PLLC
Entity Type:Organization
Organization Name:WHITEHEAD WOUND CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP-C
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESA
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:601-395-2585
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-0756
Mailing Address - Country:US
Mailing Address - Phone:601-395-2585
Mailing Address - Fax:
Practice Address - Street 1:427 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2350
Practice Address - Country:US
Practice Address - Phone:601-835-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06475799Medicaid