Basic Information
| Provider Information | |||||||||
| NPI: | 1225516354 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITEHEAD WOUND CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 756 | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396310756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013952585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 427 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018359444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | WHITEHEAD | ||||||||
| AuthorizedOfficialFirstName: | LESA | ||||||||
| AuthorizedOfficialMiddleName: | COLLEEN | ||||||||
| AuthorizedOfficialTitleorPosition: | NP-C | ||||||||
| AuthorizedOfficialTelephone: | 6013952585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | NP-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R853722 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 06475799 | 05 | MS | MEDICAID |