Provider Demographics
NPI:1417562679
Name:WHITE, AMBER R
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:R
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 1:105 SANTA CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-3627
Mailing Address - Country:US
Mailing Address - Phone:937-559-1986
Mailing Address - Fax:
Practice Address - Street 1:105 SANTA CLARA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-3627
Practice Address - Country:US
Practice Address - Phone:937-559-1986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400965110809374U00000X
OH0211326374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide