Provider Demographics
NPI:1952998221
Name:WHITE, CLARA LEE RENIA (RN BSN)
Entity Type:Individual
Prefix:
First Name:CLARA LEE
Middle Name:RENIA
Last Name:WHITE
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 PIERCE MANSE LOOP
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-8541
Mailing Address - Country:US
Mailing Address - Phone:501-240-8771
Mailing Address - Fax:
Practice Address - Street 1:8900 SHILOH DR
Practice Address - Street 2:
Practice Address - City:MABELVALE
Practice Address - State:AR
Practice Address - Zip Code:72103-2141
Practice Address - Country:US
Practice Address - Phone:501-240-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR42861163W00000X, 163WC1400X, 163WC1500X, 163WC1600X, 163WH0200X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1400XNursing Service ProvidersRegistered NurseCollege Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WH0200XNursing Service ProvidersRegistered NurseHome Health