Provider Demographics
NPI:1306197876
Name:WHITE, TINA
Entity Type:Individual
Prefix:
First Name:TINA
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 1:100 WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1063
Mailing Address - Country:US
Mailing Address - Phone:314-921-9498
Mailing Address - Fax:314-921-9948
Practice Address - Street 1:100 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5921
Practice Address - Country:US
Practice Address - Phone:314-921-9498
Practice Address - Fax:314-921-9948
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000149870374U00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide