Basic Information
| Provider Information | |||||||||
| NPI: | 1700419926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITFIELD | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ALYSSA CREW | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CREW | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | ALYSSA CLAYTON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 12938 | ||||||||
| Address2: | C/O CLINIC MANAGEMENT | ||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066027800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21 COMMERCE PKWY | ||||||||
| Address2: | |||||||||
| City: | ADAIRSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301032009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707739201 | ||||||||
| FaxNumber: | 7707739219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2020 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN249030 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.