Provider Demographics
NPI:1437493228
Name:WHITEHEAD, TINA (APRN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:STIDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21154 HIGHWAY 421 STE A
Mailing Address - Street 2:
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-8553
Mailing Address - Country:US
Mailing Address - Phone:606-672-1144
Mailing Address - Fax:606-672-1145
Practice Address - Street 1:21154 HIGHWAY 421 STE A
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749-8553
Practice Address - Country:US
Practice Address - Phone:606-672-1144
Practice Address - Fax:606-672-1145
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007764363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000812693OtherANTHEM - HYDEN
KY7100252530Medicaid
KY000000813017OtherANTHEM - HAZARD