Provider Demographics
NPI:1639142557
Name:WHITEHEAD, SHIRLEY E (WHCNP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:E
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2130
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2130
Mailing Address - Country:US
Mailing Address - Phone:928-367-4257
Mailing Address - Fax:928-367-4361
Practice Address - Street 1:728 E WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935
Practice Address - Country:US
Practice Address - Phone:928-367-4257
Practice Address - Fax:928-367-4361
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN071478363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
75283Medicare ID - Type Unspecified
S91860Medicare UPIN