Provider Demographics
NPI:1093962714
Name:WHITESIDES, CAROL MANNING
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MANNING
Last Name:WHITESIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:MANNING
Other - Last Name:WHITESIDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:89 WHITESIDES ST
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4337
Mailing Address - Country:US
Mailing Address - Phone:801-721-9914
Mailing Address - Fax:
Practice Address - Street 1:1575 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-1610
Practice Address - Country:US
Practice Address - Phone:801-957-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT197834-8900363LF0000X
UT1978348900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870532738005Medicaid