Provider Demographics
NPI:1801652466
Name:WHATLEY, PEYTON YVETTE (PTA)
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:YVETTE
Last Name:WHATLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 SIRMAN RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-4116
Mailing Address - Country:US
Mailing Address - Phone:318-780-3161
Mailing Address - Fax:
Practice Address - Street 1:6969 FERN LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4159
Practice Address - Country:US
Practice Address - Phone:318-383-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA11034R2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine