Provider Demographics
NPI:1912565789
Name:WHITE, ELLEN NICOLE (MA)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:NICOLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 DEERFIELD BLVD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2696
Mailing Address - Country:US
Mailing Address - Phone:716-307-9485
Mailing Address - Fax:
Practice Address - Street 1:3900 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504-1203
Practice Address - Country:US
Practice Address - Phone:757-625-5363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14556235Z00000X
VA2202010702235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist