Provider Demographics
NPI:1457824799
Name:WHITLEY, CLINTON HARRIS (CRNA, DNP)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:HARRIS
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:CRNA, DNP
Other - Prefix:
Other - First Name:CLINT
Other - Middle Name:H
Other - Last Name:WHITLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1010 HAMPTON FALL BLVD APT 1101
Mailing Address - Street 2:
Mailing Address - City:BROWNSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35741-8025
Mailing Address - Country:US
Mailing Address - Phone:601-310-4102
Mailing Address - Fax:
Practice Address - Street 1:101 SIVLEY RD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4421
Practice Address - Country:US
Practice Address - Phone:256-265-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-172791367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered