Provider Demographics
NPI:1598017014
Name:WHITE, IRIS NICHOLE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:IRIS
Middle Name:NICHOLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:IRIS
Other - Middle Name:NICHOLE
Other - Last Name:WHITE-JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9201 S DREXEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-7724
Mailing Address - Country:US
Mailing Address - Phone:773-754-9242
Mailing Address - Fax:
Practice Address - Street 1:9201 S DREXEL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-7724
Practice Address - Country:US
Practice Address - Phone:773-754-9242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227012364225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist