Provider Demographics
NPI:1982122560
Name:WHITEHEAD, THOMAS LEE JR (FNP-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
Last Name:WHITEHEAD
Suffix:JR
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 VALLE VERDE LN
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-8003
Mailing Address - Country:US
Mailing Address - Phone:769-960-2376
Mailing Address - Fax:
Practice Address - Street 1:207 W LEGION RD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7780
Practice Address - Country:US
Practice Address - Phone:760-351-3130
Practice Address - Fax:760-351-3130
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007261363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner