Healthcare Provider Details

I. General information

NPI: 1194689034
Provider Name (Legal Business Name): TIA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 SYLVANIA CT SE
MABLETON GA
30126-5673
US

IV. Provider business mailing address

812 SYLVANIA CT SE
MABLETON GA
30126-5673
US

V. Phone/Fax

Practice location:
  • Phone: 404-721-7386
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN248677
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: