Provider Demographics
NPI:1831608959
Name:WHITE, ANTONIO
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 N HIGHLAND AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3450
Mailing Address - Country:US
Mailing Address - Phone:731-736-1090
Mailing Address - Fax:731-736-1760
Practice Address - Street 1:1408 N HIGHLAND AVE STE 306
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3450
Practice Address - Country:US
Practice Address - Phone:731-736-1090
Practice Address - Fax:731-736-1760
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018345Medicaid