Provider Demographics
NPI:1578847034
Name:WHITE, ALICIA LUTGARDA (NP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:LUTGARDA
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 1:639 BEAVER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-3085
Mailing Address - Country:US
Mailing Address - Phone:714-932-8336
Mailing Address - Fax:
Practice Address - Street 1:6451 N FEDERAL HWY STE 800
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1409
Practice Address - Country:US
Practice Address - Phone:954-837-2356
Practice Address - Fax:866-889-7834
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177120363L00000X, 363LA2200X
NE114628363LA2200X, 363LG0600X
NE114325363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology