Basic Information
| Provider Information | |||||||||
| NPI: | 1700221801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | KAELA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FIELDS | ||||||||
| OtherFirstName: | KAELA | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 1459 S CENTER RD | ||||||||
| Address2: | |||||||||
| City: | BURTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485091726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104960900 | ||||||||
| FaxNumber: | 8107423891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2013 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704295204 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | RN277074 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.