Healthcare Provider Details

I. General information

NPI: 1114435039
Provider Name (Legal Business Name): WAVERLYN WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 E 6TH ST
LONG BEACH CA
90802-1402
US

IV. Provider business mailing address

351 E 6TH ST
LONG BEACH CA
90802-1402
US

V. Phone/Fax

Practice location:
  • Phone: 562-435-7350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: