Provider Demographics
NPI:1245514447
Name:WHITWORTH, SALLY LOU (PA-C)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:LOU
Last Name:WHITWORTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 91988
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-1988
Mailing Address - Country:US
Mailing Address - Phone:863-686-2728
Mailing Address - Fax:863-686-6737
Practice Address - Street 1:135 E. FIRST STREET
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4609
Practice Address - Country:US
Practice Address - Phone:863-686-2728
Practice Address - Fax:863-686-6737
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106097363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical