Provider Demographics
NPI:1558145193
Name:WHITE, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
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 1:415 N 86TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-2724
Mailing Address - Country:US
Mailing Address - Phone:618-210-1426
Mailing Address - Fax:
Practice Address - Street 1:415 N 86TH ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-2724
Practice Address - Country:US
Practice Address - Phone:618-210-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide