Basic Information
| Provider Information | |||||||||
| NPI: | 1114316650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WALLER | ||||||||
| OtherFirstName: | JANET | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 682 HEMLOCK ST | ||||||||
| Address2: | SUITE 490 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312016883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787411208 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 682 HEMLOCK ST | ||||||||
| Address2: | SUITE 490 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312016883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787411208 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2015 | ||||||||
| LastUpdateDate: | 11/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN154923 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | RN154923 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.