Provider Demographics
NPI:1598533911
Name:WHITLEY, DESDEMONA (DC)
Entity Type:Individual
Prefix:DR
First Name:DESDEMONA
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 SAN BERNARDINO AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-4632
Mailing Address - Country:US
Mailing Address - Phone:619-889-8834
Mailing Address - Fax:
Practice Address - Street 1:4060 FAIRMONT AVE.
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105
Practice Address - Country:US
Practice Address - Phone:619-889-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28762111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor