Provider Demographics
NPI:1760111660
Name:WHITEHEAD, COREYONNA DURAYNE (NP)
Entity Type:Individual
Prefix:
First Name:COREYONNA
Middle Name:DURAYNE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COREYONNA
Other - Middle Name:DURAYNE
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3303 QUARTER HORSE LN
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-4400
Mailing Address - Country:US
Mailing Address - Phone:678-830-6374
Mailing Address - Fax:
Practice Address - Street 1:5700 HILLANDALE DR STE 290
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4120
Practice Address - Country:US
Practice Address - Phone:678-367-3212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA268388363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily