Provider Demographics
NPI:1740946888
Name:WHITE, SALLY ANN
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
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 1:311 JACHETTA RD
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-6782
Mailing Address - Country:US
Mailing Address - Phone:208-610-0481
Mailing Address - Fax:
Practice Address - Street 1:311 JACHETTA RD
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-6782
Practice Address - Country:US
Practice Address - Phone:208-610-0481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider