Provider Demographics
NPI:1427042548
Name:WHITESELL, CONNIE S (NP)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:S
Last Name:WHITESELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:320 N OAK AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2440
Practice Address - Country:US
Practice Address - Phone:931-528-5547
Practice Address - Fax:931-526-2699
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6705363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3378641Medicaid
TN500014818OtherRAILROAD MEDICARE
TN4006810OtherBLUE CROSS BLUE SHEILD
TN3907070Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL