Basic Information
| Provider Information | |||||||||
| NPI: | 1457992497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | CELESTE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 EDMUNDSON PL | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123964000 | ||||||||
| FaxNumber: | 7123967069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2019 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 115467 | IA | N | Nursing Service Providers | Registered Nurse | 363L00000X | A156727 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 47068731712 | 05 | NE | MEDICAID | 47068731777 | 05 | NE | MEDICAID | 1457992497 | 05 | IA | MEDICAID |