Provider Demographics
NPI:1689173700
Name:WHITE, CHARISSA ANTIONETTE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CHARISSA
Middle Name:ANTIONETTE
Last Name:WHITE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 MAPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-3722
Mailing Address - Country:US
Mailing Address - Phone:757-729-6929
Mailing Address - Fax:
Practice Address - Street 1:2814 MAPLETON AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504-3722
Practice Address - Country:US
Practice Address - Phone:757-729-6929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-04
Last Update Date:2018-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60666026343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)