Provider Demographics
NPI:1750674651
Name:WHITE, SHAWN PRENTICE
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:PRENTICE
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4532 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-2726
Mailing Address - Country:US
Mailing Address - Phone:513-465-1082
Mailing Address - Fax:
Practice Address - Street 1:4532 MILLER RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-2726
Practice Address - Country:US
Practice Address - Phone:513-465-1082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRQ174143164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse