Provider Demographics
NPI:1154944130
Name:WHITE, STEPHANIE NICHELLE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICHELLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLE
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2908 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-1110
Mailing Address - Country:US
Mailing Address - Phone:510-866-5259
Mailing Address - Fax:
Practice Address - Street 1:2712 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1117
Practice Address - Country:US
Practice Address - Phone:510-548-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program