Provider Demographics
NPI:1932665007
Name:WHITE, KEIRA ROSE
Entity Type:Individual
Prefix:MS
First Name:KEIRA
Middle Name:ROSE
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 1:7 W SHAWNEE TRL
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07885-2921
Mailing Address - Country:US
Mailing Address - Phone:973-229-4746
Mailing Address - Fax:
Practice Address - Street 1:7 W SHAWNEE TRL
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:NJ
Practice Address - Zip Code:07885-2921
Practice Address - Country:US
Practice Address - Phone:973-229-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer