Basic Information
| Provider Information | |||||||||
| NPI: | 1710251129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1684 | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859411684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285941731 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 W HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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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 | 4704189759 | MI | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1871523191 | 05 | AZ | MEDICAID |