Basic Information
| Provider Information | |||||||||
| NPI: | 1396886834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | TAMARA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NORTHLAND BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136724128 | ||||||||
| FaxNumber: | 5136724479 | ||||||||
| Practice Location | |||||||||
| Address1: | 5940 MERCHANT DR | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410421158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136724128 | ||||||||
| FaxNumber: | 5136724479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363L00000X | 1080720 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2182169 | 05 | OH | MEDICAID | 78003365 | 05 | KY | MEDICAID |