Basic Information
| Provider Information | |||||||||
| NPI: | 1992128383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILHITE | ||||||||
| FirstName: | SAVANNAH | ||||||||
| MiddleName: | MALLORY | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10123 SE MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032572500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1695 MAIN STREET | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137395572 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2014 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 1-143128 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 2324823 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 201507674NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.