Provider Demographics
NPI:1891738340
Name:WHITE, KIM (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:ILENE
Other - Last Name:OHMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:5435 FREDERICK LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7479
Mailing Address - Country:US
Mailing Address - Phone:386-767-1967
Mailing Address - Fax:
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2781
Practice Address - Country:US
Practice Address - Phone:386-258-1375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2008492367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG1996Medicare ID - Type Unspecified