Healthcare Provider Details

I. General information

NPI: 1003674946
Provider Name (Legal Business Name): TYLER LEE WHITE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 LINCOLN AVE
BEDFORD IN
47421-2142
US

IV. Provider business mailing address

6402 ASBELL RD
SHOALS IN
47581-7839
US

V. Phone/Fax

Practice location:
  • Phone: 812-675-4470
  • Fax: 812-675-4469
Mailing address:
  • Phone: 812-296-8238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71015039A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: