Provider Demographics
NPI:1457815466
Name:WHITE, JOHANNA LEIGH (MA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:LEIGH
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SOUTH BLVD APT 566
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6534
Mailing Address - Country:US
Mailing Address - Phone:910-233-2547
Mailing Address - Fax:
Practice Address - Street 1:12420 BAILEY RD
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-9134
Practice Address - Country:US
Practice Address - Phone:980-344-0514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-29252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer