Provider Demographics
NPI:1790478162
Name:WHITE, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
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 1:450 SOUTH AVE APT 361
Mailing Address - Street 2:
Mailing Address - City:GARWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07027-1286
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 US HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3577
Practice Address - Country:US
Practice Address - Phone:973-467-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant