Provider Demographics
NPI:1770256703
Name:WHITE, CELESTE MAGEN (APRN)
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:MAGEN
Last Name:WHITE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12001 GOFF LN
Mailing Address - Street 2:
Mailing Address - City:FAIRDALE
Mailing Address - State:KY
Mailing Address - Zip Code:40118-9453
Mailing Address - Country:US
Mailing Address - Phone:502-358-5215
Mailing Address - Fax:502-384-5372
Practice Address - Street 1:3906 S DUPONT SQ STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4647
Practice Address - Country:US
Practice Address - Phone:502-358-5215
Practice Address - Fax:502-384-5372
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3016129OtherSTATE LICENSE