Provider Demographics
NPI:1629688122
Name:WHITAKER, AKETRE
Entity Type:Individual
Prefix:
First Name:AKETRE
Middle Name:
Last Name:WHITAKER
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 1:408 SANDERS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27801-7839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:526 COKER TOWN RD
Practice Address - Street 2:
Practice Address - City:WHITAKERS
Practice Address - State:NC
Practice Address - Zip Code:27891-8942
Practice Address - Country:US
Practice Address - Phone:252-228-5852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC110809325Medicaid
1108090325OtherPRIVATE