Provider Demographics
NPI:1821644527
Name:WHITEHEAD, TAURENCE
Entity Type:Individual
Prefix:
First Name:TAURENCE
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 JERI DR
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3840
Mailing Address - Country:US
Mailing Address - Phone:904-994-0995
Mailing Address - Fax:
Practice Address - Street 1:453 JERI DR
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-3840
Practice Address - Country:US
Practice Address - Phone:904-994-0995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program