Healthcare Provider Details

I. General information

NPI: 1124790423
Provider Name (Legal Business Name): DE ARA ANNISE WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date: 05/12/2026
Reactivation Date: 06/11/2026

III. Provider practice location address

3707 CONVOY ST
SAN DIEGO CA
92111-3754
US

IV. Provider business mailing address

3707 CONVOY ST
SAN DIEGO CA
92111-3754
US

V. Phone/Fax

Practice location:
  • Phone: 858-573-9368
  • Fax:
Mailing address:
  • Phone: 619-987-8584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: