Provider Demographics
NPI:1801224043
Name:WHITLEY, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:WHITLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1260 N DUTTON AVE
Mailing Address - Street 2:#275
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4659
Mailing Address - Country:US
Mailing Address - Phone:707-206-7268
Mailing Address - Fax:707-206-7254
Practice Address - Street 1:1260 N DUTTON AVE
Practice Address - Street 2:#275
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4659
Practice Address - Country:US
Practice Address - Phone:707-206-7268
Practice Address - Fax:707-206-7254
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA824671390200000X
CA2014010936363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program