Provider Demographics
NPI:1588152292
Name:WHITE, ELIZABETH NICOLE (DO)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7343
Mailing Address - Country:US
Mailing Address - Phone:423-989-4050
Mailing Address - Fax:423-990-3044
Practice Address - Street 1:208 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7343
Practice Address - Country:US
Practice Address - Phone:423-989-4050
Practice Address - Fax:423-990-3044
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ042000Medicaid