Provider Demographics
NPI:1245316843
Name:WHITE NEE, WANDA (PT)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:
Last Name:WHITE NEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 SW 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-3316
Mailing Address - Country:US
Mailing Address - Phone:815-341-5979
Mailing Address - Fax:
Practice Address - Street 1:1722 SW 10TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-3316
Practice Address - Country:US
Practice Address - Phone:815-341-5979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28067225100000X
IL070011646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00390229OtherRAILROAD MEDICARE PTAN
ILDF7483OtherRAILROAD MEDICARE GROUP NUMBER
IL3232028OtherBLUE CROSS BLUE SHIELD
ILP00390229OtherRAILROAD MEDICARE PTAN
IL3232028OtherBLUE CROSS BLUE SHIELD
ILDF7483OtherRAILROAD MEDICARE GROUP NUMBER