Provider Demographics
NPI:1124790423
Name:WHITE, DE ARA ANNISE
Entity type:Individual
Prefix:
First Name:DE ARA
Middle Name:ANNISE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 CAL ORCHID PL UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3226
Mailing Address - Country:US
Mailing Address - Phone:619-987-8584
Mailing Address - Fax:
Practice Address - Street 1:5998 ALCALA PARK
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2492
Practice Address - Country:US
Practice Address - Phone:260-230-8260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer