Provider Demographics
NPI:1003566274
Name:WHITE, SHANEE
Entity Type:Individual
Prefix:
First Name:SHANEE
Middle Name:
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 1:3540 PUMP RD STE 1245
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1115
Mailing Address - Country:US
Mailing Address - Phone:804-925-8133
Mailing Address - Fax:
Practice Address - Street 1:8503 PATTERSON AVE STE F
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6442
Practice Address - Country:US
Practice Address - Phone:804-740-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019018993225700000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003566274Medicaid