Provider Demographics
NPI:1205880721
Name:WHITLOCK, DONNA
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:WHITLOCK
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 1:138 LESLIE DR
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-3745
Mailing Address - Country:US
Mailing Address - Phone:910-389-9797
Mailing Address - Fax:
Practice Address - Street 1:317 WESTERN BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6338
Practice Address - Country:US
Practice Address - Phone:910-577-4740
Practice Address - Fax:910-577-2575
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC026851367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00007OtherBLUE CROSS
NC3400042Medicaid
NC3400042Medicaid