Provider Demographics
NPI:1346207107
Name:WHITEHEAD, DONNA MAE (RN)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MAE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 EXPO DR
Mailing Address - Street 2:# 108
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-8336
Mailing Address - Country:US
Mailing Address - Phone:920-684-5460
Mailing Address - Fax:920-684-5460
Practice Address - Street 1:5140 EXPO DR
Practice Address - Street 2:# 108
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-8336
Practice Address - Country:US
Practice Address - Phone:920-684-5460
Practice Address - Fax:920-684-5460
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38332700Medicaid