Provider Demographics
NPI:1124796370
Name:WHITE, ELIZABETH ANNE (RD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:WHITE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 FOX RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-1382
Mailing Address - Country:US
Mailing Address - Phone:860-338-9133
Mailing Address - Fax:
Practice Address - Street 1:2790 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4607
Practice Address - Country:US
Practice Address - Phone:860-430-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPENDING133V00000X
CT18004653203133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered