Provider Demographics
NPI:1528025624
Name:WHITE, PANDORA LEE (RN CNP)
Entity Type:Individual
Prefix:MRS
First Name:PANDORA
Middle Name:LEE
Last Name:WHITE
Suffix:
Gender:F
Credentials:RN CNP
Other - Prefix:MRS
Other - First Name:PANDORA
Other - Middle Name:LEE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN CNP
Mailing Address - Street 1:2515 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-1736
Mailing Address - Country:US
Mailing Address - Phone:612-354-2629
Mailing Address - Fax:612-354-2740
Practice Address - Street 1:2515 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-1736
Practice Address - Country:US
Practice Address - Phone:612-354-2629
Practice Address - Fax:612-354-2740
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1127607363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN765523100Medicaid
P12216Medicare UPIN
500001318Medicare ID - Type Unspecified