Basic Information
| Provider Information | |||||||||
| NPI: | 1639558083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | DEVIN | ||||||||
| MiddleName: | MILES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 858 EASTERN BYP | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404752512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596260072 | ||||||||
| FaxNumber: | 8596269684 | ||||||||
| Practice Location | |||||||||
| Address1: | 858 EASTERN BYP | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404752512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596260072 | ||||||||
| FaxNumber: | 8596269684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2015 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3009392 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3009392 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100388860 | 05 | KY | MEDICAID |