Provider Demographics
NPI:1255424511
Name:WHITE, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
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 1:2500 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9774
Mailing Address - Country:US
Mailing Address - Phone:815-844-5115
Mailing Address - Fax:815-842-2152
Practice Address - Street 1:2500 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9774
Practice Address - Country:US
Practice Address - Phone:815-844-5115
Practice Address - Fax:815-842-2152
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041150317/209001451363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL504470Medicare ID - Type UnspecifiedINDIVIDUAL #
IL833230Medicare ID - Type UnspecifiedGROUP # - PONTIAC
S64869Medicare UPIN
ILCA2182Medicare ID - Type UnspecifiedRR GROUP #
IL500007025Medicare ID - Type UnspecifiedRR INDIVIDUAL #
ILK36005Medicare ID - Type UnspecifiedINDIVIDUAL # PONTIAC