Provider Demographics
NPI:1376524389
Name:WHITE, GEORGIA J (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:J
Last Name:WHITE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 E TOMLINSON ST
Mailing Address - Street 2:
Mailing Address - City:POYNETTE
Mailing Address - State:WI
Mailing Address - Zip Code:53955-8574
Mailing Address - Country:US
Mailing Address - Phone:608-635-8936
Mailing Address - Fax:
Practice Address - Street 1:236 E TOMLINSON ST
Practice Address - Street 2:
Practice Address - City:POYNETTE
Practice Address - State:WI
Practice Address - Zip Code:53955-8574
Practice Address - Country:US
Practice Address - Phone:608-635-8936
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31125-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI399-30-700Medicaid