Provider Demographics
NPI:1457102717
Name:WHITE, SHATAVIA J
Entity Type:Individual
Prefix:
First Name:SHATAVIA
Middle Name:J
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 1:8165 E B COOPER HWY
Mailing Address - Street 2:
Mailing Address - City:RICEBORO
Mailing Address - State:GA
Mailing Address - Zip Code:31323-3214
Mailing Address - Country:US
Mailing Address - Phone:912-321-1077
Mailing Address - Fax:
Practice Address - Street 1:3100 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-5514
Practice Address - Country:US
Practice Address - Phone:912-427-6873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004560225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant