Provider Demographics
NPI:1679060735
Name:WHATLEY, GAYLE MARIE
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:MARIE
Last Name:WHATLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W CLARKSTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-4101
Mailing Address - Country:US
Mailing Address - Phone:248-814-8525
Mailing Address - Fax:
Practice Address - Street 1:400 W CLARKSTON RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-4101
Practice Address - Country:US
Practice Address - Phone:248-814-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-15
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBA0000450246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical