Provider Demographics
NPI:1548561145
Name:WHITEHURST, KISHA N (LMT)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:N
Last Name:WHITEHURST
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2469 QUARTERHORSE TRL
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-4428
Mailing Address - Country:US
Mailing Address - Phone:904-718-2289
Mailing Address - Fax:
Practice Address - Street 1:2469 QUARTERHORSE TRL
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-4428
Practice Address - Country:US
Practice Address - Phone:904-718-2289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47060225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist