Provider Demographics
NPI:1073976700
Name:WHITE, TONYA SUE (NP-C)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:SUE
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 LAKE LAND BLVD
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5283
Mailing Address - Country:US
Mailing Address - Phone:121-761-9273
Mailing Address - Fax:
Practice Address - Street 1:501 LAKE LAND BLVD
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5283
Practice Address - Country:US
Practice Address - Phone:217-258-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014037363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner