Healthcare Provider Details

I. General information

NPI: 1457765034
Provider Name (Legal Business Name): DAWN WHITE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DAWN DEANNE WHITE PTA

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 CROSSGATES BLVD
BRANDON MS
39042-2602
US

IV. Provider business mailing address

4876 WINDERMERE TER
JACKSON MS
39206-4828
US

V. Phone/Fax

Practice location:
  • Phone: 601-316-7632
  • Fax:
Mailing address:
  • Phone: 601-316-7632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4991
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: