Provider Demographics
NPI:1700221801
Name:WHITE, KAELA RAE (NP)
Entity Type:Individual
Prefix:
First Name:KAELA
Middle Name:RAE
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KAELA
Other - Middle Name:RAE
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:1459 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1726
Practice Address - Country:US
Practice Address - Phone:810-496-0900
Practice Address - Fax:810-742-3891
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704295204363L00000X
GARN277074363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner