Provider Demographics
NPI:1316930795
Name:WHITEHEAD, JANIS J (RN, FNP)
Entity type:Individual
Prefix:
First Name:JANIS
Middle Name:J
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 WHEATLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-9407
Mailing Address - Country:US
Mailing Address - Phone:309-252-1084
Mailing Address - Fax:
Practice Address - Street 1:66 N 6TH ST
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:WA
Practice Address - Zip Code:99347-9705
Practice Address - Country:US
Practice Address - Phone:509-843-1591
Practice Address - Fax:509-843-1234
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001099363L00000X
WAAP60594743363L00000X
ID56229363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S46649Medicare UPIN
524420Medicare ID - Type Unspecified