Provider Demographics
NPI:1376593160
Name:WHITAKER, JULIE KAY (MPA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:KAY
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MPA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:KAY
Other - Last Name:DEYOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 EAST BELTLINE N.E.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-752-6235
Mailing Address - Fax:616-752-6324
Practice Address - Street 1:53880 CARMICHAEL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1567
Practice Address - Country:US
Practice Address - Phone:574-247-9441
Practice Address - Fax:574-247-9442
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002909A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10002909AOtherINDIANA LICENSING AGENCY