MEDICARE: MS. WANDA WHITE NEE PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT28067	FL
2	225100000X	Physical Therapist	070011646	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00390229	OTHER	IL	RAILROAD MEDICARE PTAN
2	DF7483	OTHER	IL	RAILROAD MEDICARE GROUP NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	3232028	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1245316843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WANDA WHITE NEE PT

Provider Business Mailing Address
First Line	:	1722 SW 10TH AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33991-3316
Country	:	US
Telephone Number	:	815-341-5979
Fax Number	:

Provider Business Practice Location Address
First Line	:	1722 SW 10TH AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33991-3316
Country	:	US
Telephone Number	:	815-341-5979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	02/28/2024

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