Provider Demographics
NPI:1710505292
Name:WHITE, KIM MARIA (RN)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIA
Last Name:WHITE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIA
Other - Last Name:BRADDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:529 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3303
Mailing Address - Country:US
Mailing Address - Phone:559-331-8603
Mailing Address - Fax:
Practice Address - Street 1:529 FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3303
Practice Address - Country:US
Practice Address - Phone:559-331-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS884964163WA0400X, 163WA2000X, 163WC1500X, 163WC1600X, 163WG0600X, 163WH0200X, 163WH1000X, 163WI0500X, 163WM0705X, 163WP0808X, 163WP0809X, 163WS0200X, 163WX0200X, 163WC0400X
MSMS163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WS0200XNursing Service ProvidersRegistered NurseSchool
No163WX0200XNursing Service ProvidersRegistered NurseOncology