Provider Demographics
NPI:1851066401
Name:WHITE, KEVIN WILLSON
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILLSON
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 1:1440 NE MERMAN DR
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5069
Mailing Address - Country:US
Mailing Address - Phone:406-812-0551
Mailing Address - Fax:
Practice Address - Street 1:1440 NE MERMAN DR
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5069
Practice Address - Country:US
Practice Address - Phone:406-812-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT367496376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4128555OtherHEALTHY MONTANA KIDS