Provider Demographics
NPI:1225618358
Name:WHITE, REGINA GAIL
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:GAIL
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 1:763 YUKON ST NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3114
Mailing Address - Country:US
Mailing Address - Phone:321-722-0475
Mailing Address - Fax:321-722-0475
Practice Address - Street 1:763 YUKON ST NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3114
Practice Address - Country:US
Practice Address - Phone:321-722-0476
Practice Address - Fax:321-722-0475
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility