Provider Demographics
NPI:1891134672
Name:WHITE, KANIKA R (NP)
Entity Type:Individual
Prefix:
First Name:KANIKA
Middle Name:R
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KANIKA
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9247
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-9247
Mailing Address - Country:US
Mailing Address - Phone:706-322-7884
Mailing Address - Fax:706-243-4356
Practice Address - Street 1:610 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-322-7884
Practice Address - Fax:706-243-4356
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171760363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140949BMedicaid
GA2025I01223Medicare PIN