Basic Information
Provider Information | |||||||||
NPI: | 1871733154 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | GINA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHITE | ||||||||
OtherFirstName: | GINA | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7687 | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | MO | ||||||||
PostalCode: | 652057687 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5738822259 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2121 SANTA MONICA BLVD | ||||||||
Address2: |   | ||||||||
City: | SANTA MONICA | ||||||||
State: | CA | ||||||||
PostalCode: | 904042303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3105827137 | ||||||||
FaxNumber: | 3105827140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2009 | ||||||||
LastUpdateDate: | 04/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2010027593 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.