Provider Demographics
NPI:1275331860
Name:WHITE, LATRELLE LACOLE
Entity type:Individual
Prefix:
First Name:LATRELLE
Middle Name:LACOLE
Last Name:WHITE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1951
Mailing Address - Country:US
Mailing Address - Phone:903-283-6076
Mailing Address - Fax:
Practice Address - Street 1:2301 VILLA DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1951
Practice Address - Country:US
Practice Address - Phone:903-283-6076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-07
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX761563163W00000X
TX1192533363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse