Healthcare Provider Details

I. General information

NPI: 1760630974
Provider Name (Legal Business Name): SHENITA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 BROOKSTONE CENTRE PKWY
COLUMBUS GA
31904-4501
US

IV. Provider business mailing address

7461 BLACKMON RD APT 4601
COLUMBUS GA
31909-8400
US

V. Phone/Fax

Practice location:
  • Phone: 706-494-7700
  • Fax:
Mailing address:
  • Phone: 404-314-2975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number076228
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: