Provider Demographics
NPI:1518478551
Name:WHITE, MARIE LATIA
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LATIA
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 1:5755 S SANDHILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2551
Mailing Address - Country:US
Mailing Address - Phone:702-433-4550
Mailing Address - Fax:
Practice Address - Street 1:1701 N GREEN VALLEY PKWY STE 9A
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5991
Practice Address - Country:US
Practice Address - Phone:702-407-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1518478551Medicaid
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