Provider Demographics
NPI: | 1710505292 |
---|---|
Name: | WHITE, KIM MARIA (RN) |
Entity Type: | Individual |
Prefix: | |
First Name: | KIM |
Middle Name: | MARIA |
Last Name: | WHITE |
Suffix: | |
Gender: | F |
Credentials: | RN |
Other - Prefix: | |
Other - First Name: | KIM |
Other - Middle Name: | MARIA |
Other - Last Name: | BRADDY |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | RN |
Mailing Address - Street 1: | 529 FOREST AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSON |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 39206-3303 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 559-331-8603 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 529 FOREST AVE |
Practice Address - Street 2: | |
Practice Address - City: | JACKSON |
Practice Address - State: | MS |
Practice Address - Zip Code: | 39206-3303 |
Practice Address - Country: | US |
Practice Address - Phone: | 559-331-8603 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2020-07-10 |
Last Update Date: | 2020-07-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MS | 884964 | 163WA0400X, 163WA2000X, 163WC1500X, 163WC1600X, 163WG0600X, 163WH0200X, 163WH1000X, 163WI0500X, 163WM0705X, 163WP0808X, 163WP0809X, 163WS0200X, 163WX0200X, 163WC0400X |
MS | MS | 163WG0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 163WC0400X | Nursing Service Providers | Registered Nurse | Case Management |
No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No | 163WA2000X | Nursing Service Providers | Registered Nurse | Administrator |
No | 163WC1500X | Nursing Service Providers | Registered Nurse | Community Health |
No | 163WC1600X | Nursing Service Providers | Registered Nurse | Continuing Education/Staff Development |
No | 163WG0000X | Nursing Service Providers | Registered Nurse | General Practice |
No | 163WG0600X | Nursing Service Providers | Registered Nurse | Gerontology |
No | 163WH0200X | Nursing Service Providers | Registered Nurse | Home Health |
No | 163WH1000X | Nursing Service Providers | Registered Nurse | Hospice |
No | 163WI0500X | Nursing Service Providers | Registered Nurse | Infusion Therapy |
No | 163WM0705X | Nursing Service Providers | Registered Nurse | Medical-Surgical |
No | 163WP0808X | Nursing Service Providers | Registered Nurse | Psychiatric/Mental Health |
No | 163WP0809X | Nursing Service Providers | Registered Nurse | Psychiatric/Mental Health, Adult |
No | 163WS0200X | Nursing Service Providers | Registered Nurse | School |
No | 163WX0200X | Nursing Service Providers | Registered Nurse | Oncology |