Provider Demographics
NPI:1760973325
Name:WHITE, MILDRED
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9343 S SANGAMON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-2734
Mailing Address - Country:US
Mailing Address - Phone:773-699-4281
Mailing Address - Fax:773-496-0909
Practice Address - Street 1:9343 S SANGAMON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-2734
Practice Address - Country:US
Practice Address - Phone:773-699-4281
Practice Address - Fax:773-496-0909
Is Sole Proprietor?:No
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X, 246Q00000X, 374700000X
ILW300-6008-4709172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology
No374700000XNursing Service Related ProvidersTechnician