Provider Demographics
NPI:1124287156
Name:WHITE, MARY KATHRYN (FNP)
Entity type:Individual
Prefix:
First Name:MARY KATHRYN
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4182
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4182
Mailing Address - Country:US
Mailing Address - Phone:307-733-6520
Mailing Address - Fax:307-733-3216
Practice Address - Street 1:555 E BROADWAY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-4182
Practice Address - Country:US
Practice Address - Phone:307-733-6520
Practice Address - Fax:307-733-3216
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY20671.0951363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily