Provider Demographics
NPI:1740261445
Name:WHITE, TAMELY D (FNP)
Entity type:Individual
Prefix:MS
First Name:TAMELY
Middle Name:D
Last Name:WHITE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 N ROAD ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3354
Mailing Address - Country:US
Mailing Address - Phone:252-335-5424
Mailing Address - Fax:252-335-1077
Practice Address - Street 1:1141 N ROAD ST
Practice Address - Street 2:STE G
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-335-5424
Practice Address - Fax:252-335-1077
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2319001OtherMEDICARE GROUP PTAN
NC5900660Medicaid