Provider Demographics
NPI:1679196158
Name:WHITLATCH, MARY SANDRA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SANDRA
Last Name:WHITLATCH
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 1:4939 W RAY RD STE 4-312
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2065
Mailing Address - Country:US
Mailing Address - Phone:602-509-5548
Mailing Address - Fax:
Practice Address - Street 1:4939 W RAY RD STE 4-312
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2065
Practice Address - Country:US
Practice Address - Phone:602-509-5548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN046779163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management