Provider Demographics
NPI:1700373966
Name:WHITE, NATHALIA WHITE SHANETTA (HEALTHCARE PROVIDER)
Entity Type:Individual
Prefix:MRS
First Name:NATHALIA WHITE
Middle Name:SHANETTA
Last Name:WHITE
Suffix:
Gender:F
Credentials:HEALTHCARE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W GALVESTON ST UNIT 417
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77574-0849
Mailing Address - Country:US
Mailing Address - Phone:281-787-2881
Mailing Address - Fax:
Practice Address - Street 1:240 W GALVESTON ST UNIT 417
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77574-0849
Practice Address - Country:US
Practice Address - Phone:281-787-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82-5132507Medicaid
TX825132507Medicaid