Provider Demographics
NPI:1093285538
Name:WHITE, AMBER DAWN
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
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 1:430 W IOWA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2826
Mailing Address - Country:US
Mailing Address - Phone:208-442-1123
Mailing Address - Fax:
Practice Address - Street 1:430 W IOWA AVE STE A
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2826
Practice Address - Country:US
Practice Address - Phone:208-442-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1305225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMASG-1305OtherMT