Healthcare Provider Details

I. General information

NPI: 1497486567
Provider Name (Legal Business Name): JALISA WHITE NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JALISA BRICE RN

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 10/31/2022
Certification Date: 10/14/2022
Deactivation Date: 07/08/2022
Reactivation Date: 10/11/2022

III. Provider practice location address

612 S 6TH ST
EDWARDSVILLE KS
66111-1393
US

IV. Provider business mailing address

612 S 6TH ST
EDWARDSVILLE KS
66111-1393
US

V. Phone/Fax

Practice location:
  • Phone: 913-309-9281
  • Fax:
Mailing address:
  • Phone: 913-309-9281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number13-131827-041
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number53-81350-041
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: