Provider Demographics
NPI:1659501955
Name:WHITE, REGINA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:MARIE
Other - Last Name:MCGLOTHLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4566
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-4566
Mailing Address - Country:US
Mailing Address - Phone:800-577-5368
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:2603 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-3807
Practice Address - Country:US
Practice Address - Phone:217-528-0307
Practice Address - Fax:217-528-0034
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0338079OtherANCC CERTIFICATION