Provider Demographics
NPI:1629615703
Name:WHITMAN, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WHITMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-2923
Mailing Address - Country:US
Mailing Address - Phone:336-740-0358
Mailing Address - Fax:
Practice Address - Street 1:1411 7TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44703-2923
Practice Address - Country:US
Practice Address - Phone:336-740-0358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001094172V00000X
OH401957970417376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No376K00000XNursing Service Related ProvidersNurse's Aide