Provider Demographics
NPI:1952910531
Name:WILSON-WHITE, SHANE R (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:R
Last Name:WILSON-WHITE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13851 N MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:CARBON
Mailing Address - State:IN
Mailing Address - Zip Code:47837-8003
Mailing Address - Country:US
Mailing Address - Phone:812-243-0799
Mailing Address - Fax:
Practice Address - Street 1:1004 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2208
Practice Address - Country:US
Practice Address - Phone:812-362-5149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010305A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily