Basic Information
| Provider Information | |||||||||
| NPI: | 1356688147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | HAYLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5316 TRAIL LAKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761331931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 723 S INTERSTATE 35 E | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762054101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003404098 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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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 | 133VN1004X | DT81993 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 149984001 | 05 | TX | MEDICAID | 207164901 | 05 | TX | MEDICAID |