Provider Demographics
NPI:1831500966
Name:WHITLEY, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WHITLEY
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 1:2700 COLTSGATE RD
Mailing Address - Street 2:101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-3799
Mailing Address - Country:US
Mailing Address - Phone:704-365-3588
Mailing Address - Fax:
Practice Address - Street 1:2700 COLTSGATE RD
Practice Address - Street 2:101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3799
Practice Address - Country:US
Practice Address - Phone:704-365-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist