Healthcare Provider Details

I. General information

NPI: 1053251462
Provider Name (Legal Business Name): KEISHA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 24
PRAIRIE MS
39756-0024
US

IV. Provider business mailing address

PO BOX 24
PRAIRIE MS
39756-0024
US

V. Phone/Fax

Practice location:
  • Phone: 652-319-7515
  • Fax:
Mailing address:
  • Phone: 652-319-7515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1000171
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: