Provider Demographics
NPI:1568595775
Name:WHITE, DEIDRA (NP)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 ANEMONE WAY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-8173
Mailing Address - Country:US
Mailing Address - Phone:404-425-8479
Mailing Address - Fax:
Practice Address - Street 1:699 CHURCH ST NE
Practice Address - Street 2:SUITE 340
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1110
Practice Address - Country:US
Practice Address - Phone:678-355-1620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA117058363L00000X
GARN 117058 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00810917BMedicaid
GA00810917BMedicaid
GA50BBFHFMedicare ID - Type Unspecified