Basic Information
Provider Information | |||||||||
NPI: | 1891134672 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | KANIKA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUSSELL | ||||||||
OtherFirstName: | KANIKA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9247 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319089247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063227884 | ||||||||
FaxNumber: | 7062434356 | ||||||||
Practice Location | |||||||||
Address1: | 610 19TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319011528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063227884 | ||||||||
FaxNumber: | 7062434356 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2013 | ||||||||
LastUpdateDate: | 05/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN171760 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 003140949B | 05 | GA |   | MEDICAID |