Healthcare Provider Details

I. General information

NPI: 1710629571
Provider Name (Legal Business Name): DA'KIRA KANISHA WHITE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5209 W WAR MEMORIAL DR
PEORIA IL
61615-9250
US

IV. Provider business mailing address

3812 W VINTON AVE
PEORIA IL
61615-2972
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-5100
  • Fax:
Mailing address:
  • Phone: 309-219-1403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041429896
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: