Provider Demographics
NPI:1104477959
Name:WHITE, ALONZO M
Entity type:Individual
Prefix:
First Name:ALONZO
Middle Name:M
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 LOUISIANA ST APT R
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-1402
Mailing Address - Country:US
Mailing Address - Phone:501-319-5614
Mailing Address - Fax:
Practice Address - Street 1:1717 LOUISIANA ST APT R
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-1402
Practice Address - Country:US
Practice Address - Phone:501-319-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR084793163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management