Provider Demographics
NPI:1740754282
Name:WHITESIDE, HAYLIE BROOKE
Entity Type:Individual
Prefix:
First Name:HAYLIE
Middle Name:BROOKE
Last Name:WHITESIDE
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 1:3873 HOLLINGSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-6611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2316 WALKER BUILDING
Practice Address - Street 2:
Practice Address - City:AUBURN UNIVERSITY
Practice Address - State:AL
Practice Address - Zip Code:36849-0001
Practice Address - Country:US
Practice Address - Phone:256-343-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12450390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program