Provider Demographics
NPI:1073909040
Name:WHITE, KENNETH RAY (PHD, A/G ACNP-BC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAY
Last Name:WHITE
Suffix:
Gender:M
Credentials:PHD, A/G ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-243-3922
Practice Address - Fax:434-244-9406
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171091363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care