Basic Information
| Provider Information | |||||||||
| NPI: | 1477959609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | KYLI | ||||||||
| MiddleName: | RIEHL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | C-PNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIEHL | ||||||||
| OtherFirstName: | KYLI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 365 STOUT DRIVE BOX 70403 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394515 | ||||||||
| FaxNumber: | 4234394060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2151 CENTURY LN | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376044469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239262500 | ||||||||
| FaxNumber: | 4239265999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2014 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 0000019324 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Q009532 | 05 | TN | MEDICAID |