1053619817 NPI number — MISS JAIMIE ADELLE WHITE PA

Table of content: MISS JAIMIE ADELLE WHITE PA (NPI 1053619817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053619817 NPI number — MISS JAIMIE ADELLE WHITE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
JAIMIE
Provider Middle Name:
ADELLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053619817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1351 ROUTE 55
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAGRANGEVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12540-5108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-475-9661
Provider Business Mailing Address Fax Number:
845-475-9938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1530 ROUTE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAPPINGERS FALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12590-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-297-2511
Provider Business Practice Location Address Fax Number:
845-297-4993
Provider Enumeration Date:
03/03/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  018605 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 018605 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04198481 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".