Provider Demographics
NPI:1124792122
Name:WHITE, CINNAMIN MARCHALL
Entity type:Individual
Prefix:
First Name:CINNAMIN
Middle Name:MARCHALL
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 1:18018 SMALLEN DR
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-8236
Mailing Address - Country:US
Mailing Address - Phone:225-610-7735
Mailing Address - Fax:
Practice Address - Street 1:18018 SMALLEN DR
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-8236
Practice Address - Country:US
Practice Address - Phone:225-610-7735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011505013171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor