Provider Demographics
NPI:1316691728
Name:WHITE, ELIZABETH ANN
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
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 1:3553 REDWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-5441
Mailing Address - Country:US
Mailing Address - Phone:937-207-8857
Mailing Address - Fax:
Practice Address - Street 1:3553 REDWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-5441
Practice Address - Country:US
Practice Address - Phone:937-207-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH104937450599Medicaid